ENERGY SOURCES IN

SURGERY
BY
DR.T.CHIDAMBARA
MODERATOR-
DR.MUGILAN
MAHATMA GANDHI
MEDICAL COLLEGE, PUDUCHERRY
 HISTO
RY
• William T.
Bovie
developed the
first
electrosurgical
device.
• The first use of an electrosurgical
generator in an operating room
occurred in 1926 at Peter Bent
Brigham Hospital in Boston,
Massachusetts.
• In 1928, Cashing first published a
series of 500 neurosurgical
 ELECTROCAUTERY
IS NOT
ELECTROSURGERY
• The terms electrocautery and
electrosurgery are frequently used
interchangeably, however these
terms define two distinctly different
modalitiesjhh
• 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
 ENERGY SOURCES
• Radiofrequency electro-
surgery
—Monopolar cautrey
—Bipolar cautrey
• Ultrasonic energy system
• LASER
• Argon beam coagulation
• Radiofrequency ablation
• Recent advances
 Electrical
circuit
Efectrosurgica! unit produces AC current

Delivered to patient tissue by instrument

Intracellular conversion of energy

Electromagnetic energy
to and fro movement of
electrons Kinetic énergy

Thermal ”energy (vaporisation,

fulgration, desiccation and coagulation)
 FREQUENCY SPECTRUM
• Standard electrical current: 60 Hz
• If current be transmitted through body
tissue at 60Hz, excessive
neuromuscular stimulation and
perhaps electrocution would result.
• Nerve and muscle stimulation cease at:
100KHz
An electrosurgical generator takes 60
Hz current and increases its
frequency to over 200 kHz
TEMPERATURE VS TISSUE
EFFECTS
• 45 degree C: collagen uncoils &
may reanneal covalent bonds b/w
edges and fuse
• 60 degree C: irreversible protein
denaturation, coagulation necrosis
begins
• 80 degree C: carbonization begins;
drying and shrinkage of tissues
• 90-100 degree C: complete cellular
destruction by vaporization; plume
of gas and smoke
•
ELECTROSURGICAL
GENERATORS
Two types of electrosurgical generators:
• Ground referenced generators (typically
older, outdated units)
• Isolated generators (today's state-
of-art technology)
 GROUNDED
ELECTROSURGI
CAL SYSTEMS
• The current passes through the patient and
returns to the generator, which is linked to
ground.
• The problem is the
current can go to any
grounded object other
than the patient return
electrode (ECG
electrodes, OR bed,
metal objects) and
cause alternate site
burns.
 ISOLATED
ELECTROSURGICAL SYSTEM
• Circuit is completed by the generator, not by
groun
• Patient return
electrode is recognized
as preferred pathway
• Hazards of current
division and alternate
site burn are
eliminated.
 PATIENT RETURN ELECTRODE
• Patient return electrodes are not
“inactive” or “passive.” The only
difference between the “active”
electrode and the patient return
electrode is their size and relative
conductivity.
• The function of a return electrode is to
remove current from patient
safely.
• At patient return electrode site:
reduced contact areal current
 BEST GROUNDING PAD
SITE
• Over a well-vascularized muscle mass
• Avoid placing grounding pad over
bony prominences, hairy sites, scar
tissue , excess adipose tissue
• Pad site should be free from lotions or
oils.
• Place grounding pad as close to the
surgical
site as possible.
• Grounding pad should be placed such
that the entire surface of the pad
 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
Complet
e
Circuit
MONOPOLAR
ELECTROSURGERY
• 4 components: generator, active
electrode, patient, patient return
electrode.
• Electrical energy flows from the
generator (ESU unit), to the active
electrode (cautery pencil).
• The energy then passes through the
patient to the dispersive cautery
pad, thus completing the
electrical circuit.
 TISSUE EFFECTS WITH
WAVEFORM
MODIFICATION
A. Cutting
• Using a constant
waveform, the surgeon is
able to vaporize or cut
tissue.
• Current flow 100% of the
cycle
• Low voltage Produce
Intense heat.
• Non-contact mode N
 Coagulatio
•nUsing an intermittent waveform the duty cycle (“on”
time) is reduced. This interrupted waveform will
produce less heat. Instead of tissue
vaporization, a coagulum is produced.
• Current flow 6P« of the cycle.
• High voltage
• Sparks across a gap to coagulate.
C.Blend
• not a mixture of both cutting and coagulation
current but
rather a modification of the duty cycle.
• As you go from Blend 1 to Blend 3 the duty cycle
is
progressively reduced.
• A lower duty cycle produces less heat.
• Desiccation
Achieved most efficiently with cutting
current.
By touching electrode to the
tissue, current concentration
reduced, result in less heat and
no cutting action
cells dry out and form a
coagulum
• Fulguration
The tip of the active electrode is not in
contact with the tissues
coagulates and chars the
tissue over a wide area, result
in coagulum
TISSUE EFFECTS CHANGE
AS YOU MODIFY THE
WAVEFORM

BLENO BLGN D BLENO COAG

I Z 3
Pure Blen Fulguration/non contact
cut d coag
 VARIABLES IMPACTING
TISSUE EFFECT
In addition to wäVRform and power setting, other
variables
impact tissue effect. They include:

• Size of the electrode: The smaller the electrode, the

higher the currE'nt concentration.

• Time: The longer the generator is activated, the more

heat is produced. And the greater the heat, the
farther it will travel to adjacent tissue
(thermal spread).

• Manipulation of the electrode:. This is a function of

current density and the resultant heat produced while
sparking to tissue versus holding the electrode in direct
contact with tissue.

• Type of Tissue: Tissues vary widely in

resistance.
 SAFETY CONSIDERATIONS
Direct Coupling
• occurs 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.
• This can also occur if an active
electrode is activated while in contact
with a metal clip.
INSULATION FAILURE
• Insulation failure can occur when the
insulation covering of an endoscopic
instrument has been damaged
• Cracks allow electrical energy to escape
and burn unintended tissue.
• The insulation of instruments must be
inspected
• Most damage to insulation occurs
during sterilization. Heat with subsequent
cooling causes insulation to shrink and
then expand. During this process cracks
and breaks can occur.
Capacitive
coupling
• During MIS procedure, an inadvertent
capacitor may be created by the surgical
instruments.
• A capacitor creates electrostatic field
created b/w two conductors, resulting
induced current in second conductor.
• Full metal cannula are the best to use.
• Hybrid cannula are worst , metal part
will create a capacitor but plastic anchor
will prevent the current from dissipating
through abdominal wall. This current may
exit to some adjacent tissue, result in
significant injury.
 ACTIVE ELECTRODE
MONITORING
• When insulation failure occurs or
capacitively coupled energy reaches
dangerous levels, the electrosurgical
unit (ESU) shuts down automatically
and the surgical staff are alerted.
• AEM system detects even the
smallest full thickness insulation
breaks on Laparoscopic instruments,
virtually eliminating accidental burns
due to faulty insulation.
BIPOLAR
ELECTROSURGERY
• The two tines forceps function as
active and
return electrodes.
• Only the tissue grasped is included in
circuit.
• No patient return
electrode
• Better hemostasis
• Less thermal injury
• Safer than monopolar

• DISADVANTAGES
- More skill required.
- Coagulation only.
 RECOMMENDATIONS TO
AVOID ELECTROSURGICAL
COMPLICATIONS
• Inspect insulation carefully
• Use lowest possiblR 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
GYRUS PK Generator
 GYRUS PK Generator
• Plasma kinetic energy delivered in
pulses
• Intermittent tissue cooling prevents
thermal
damage and sticking.
• PK energy to tissue C forms vapour
zones Ccurrent passes
around the vapour zones vapour
zone collapses causing tissue sealing.
 VESSEL
SEALING
TECHNOLO
GY
• Ligasur
e
° Enseal
 LIGASURE
• Combination of pressure and energy to
create a
seal.
• ”Electrosurgical collagen welding”
combination of pressure and energyN
denature collagen and elastinN
Permanent seal.
• Feedback controlled output so reliable seal
in
minimal time
• Average seal cycle is 2-4 sec.
• Energy delivery cycle:
-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.
 ENSEAL
• Smart electrode technology — millions
of nano conductive particles each
with discrete thermostatic switch.
• Each particle interrupts current flow
to a specific tissue when
temperature rises.
• Adjusts energy according to tissue
impedance
• If temperature below fusion level it
turns back on.
• Less heat required. Tissue volume
reduced by compression.
• Vessel walls fused by compression
and protien denaturation.
• Seals upto 7 mm vessels. Thermal
spread 1 mm
• Withstands upto 7 times systolic
pressures.
ULTRASONIC ENERGY
DEVICES
• The harmonic scalpel uses ultrasound
technology to dissect tissue with only
minimal collateral tissue damage.
• The device vibrates at a high
frequency, approximately 55,000
times/second, to cut tissue.
• The high frequency vibration of tissue
molecules generates stress and
friction in the tissue, which in turn
generates heat and denaturation of
protein.
• Thus simultaneous cutting and
coagulation to take place
• provide excellent hemostasis, efficient
transection, minimal lateral thermal
damage, low smoke generation, and
no risk of electrical current passage to
the patient.
• Safely coagulates and transect vessels
upto 5 mm
Disadvantages
• inability to coagulate vessels
greater than Smm.
• Operator dependence of settings of
the blade according to tissue.
• Increased cost.
• THUNDERBEAT is integration of bDth
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.
• Advantages
•Reliable 7 mm vessel sealing
Minimal thermal spread
• Quickest in-its-class cutting
CAVITRON ULTRASONIC
SURGICAL
ASPIRATOR(CUSA)

C••loon Tod uhre inle sotglcd

apknler.
• Cavitron ultrasonic surgical
aspirator(CUSA) is a dissecting device
that uses low ultrasonic frequencies to
fragment tissue.
• Utilizing a hollow titanium tip that
vibrates along its longitudinal aKis,
fragmentation of susceptible tissue
occurs while concurrently lavaging
and aspirating material from the
surgical site.
• It is basically an ultrasound probe
combined with a suction device.
• The CUSA selectively ablates tissues
with high water content such as
liver parenchyma, glandular, and
neoplastic tissue.
• The advantages of using this device
are less blood loss, improved
visibility, and reduced collateral
tissue injury.
• This instrument is most useful when
removing “non-resectable” brain
and spine tumors, noncirrhotic liver
and pancreatic tumors.
 LAS
(Light Amplification ER
by Stimulated
Emission of Radiation)

• Lasers use photons to excite the

chromophore molecules within target
tissue and generate kinetic energy
that is relea5ed as heat, which
causes protein denaturation and
coagulation necrosis.
• It can be applied to the surface of target
tissue or interstitially with a
fiberoptic probe placed under precision
image guidance.
• The energy generated and the depth of
tissue penetration depends on the power
 argon, carbon
• common dioxide
types: neodymium:yttr
ium-
aluminum-garnet (Nd-YAG) lasers.
• Penetration
Nd-YAG Iaser> carbon dioxide>
argon
• The optical properties of different
tumors or tissues are markedly
different and depend on their
tissue composition, density, degree of
parenchymal fibrosis, vascularity, and
ARGON ENHANCED
ELECTROSURGERY
 ARGON ENHANCED
•ELECTROSURGERY
It creates monopolar electric circuit between a
hand held probe and the target tissue by
establishing a steady flow of electrons
through a channel of electrically activated and
ionized argon gas.
• This high-flow argon gas conducts electrical
current to the target tissue and generates
thermal coagulation of this tissue.
• The argon gas blows blood away from the
surface of the target so it improves visibility.
• It is most commonly used to treat parenchymal
hemorrhage of an organ, particularly the liver,
but can be used on the spleen, kidney, or
any other solid organ with surface
 Y
RADIOFREDUENC
ABLATION
• The basic methOd of radiofrequency application
is to place an electrode (or electrodes) into
or over the target tissue to transmit a
high-frequency alternating current to the
tissue in the range of 350 to 500 kHz.
• Creating alternating electrical field•g' induces
motion of
ionsW kinectic energy converted into heat
(>100• C)
R coagulation necrosis.
• It has a built in sensor for automatically
terminating transmission of the current at a
particular set point to prevent overheating and
unwanted collateral damage.
• It is used for tumors in the liver
parenchyma, lung, kictney, adrenal
 RECENT ADVANCES
• Photodynamic
Therapy
• Cryotherapy
• Microwave
ablation
• Radiosurgery
• Hydrojet Device
• Floating Ball
 PHOTODYNAMIC
THERAPY
• Begins with the administration of a target-
specific photosensitizer that is eventually
concentrated in the target tissue.
• The photosensitizing agent is then
activated with a wavelength-specific light
energy source, which leads to the generation
of free radicals cytotoxic to the target tissue.
• Used in treating early radiologically detected
non— small cell lung cancer, pancreatic
cancer, squamous cell and basal cell
carcinoma of the skin, recurrent superficial
bladder cancer, chest wall involvement
from breast cancer, and even chest wall
 CRYOTHERA
PY
• It destroys cells by freezing and thawing.
• With liquid nitrogen or argon circulating through a probe
Placed over or within the target lesion, the tissue
can be frozen to a temperature of —35° C or
lower.
• Cell damage occurs as a result of disruption of
subcellular
structures, with ice crvstalformation in the freezing
phase
and degradation during the thawing process.
• Lesions that contact major vessels can be difficult to
treat with this modality, because of the heat sink
effect introduced by circulating blood.
• Used for cutaneous lesions, tumours of the head and
neck, cervix, rectum, prostate, breast and liver.
• The major disadvantage of cryotherapy is its cost.
• Complications such as hemorrhage from tissue
 MICROWAVE ABLATION
• Microwave coagulation is achieved by
using a generator to transmit
microwave energy at a frequency of
2450 MHz via a probe placed under
image guidance within target organs
or tissue.
• Applications — liver, prostatic
hyperplasia,
endometrial bleeding, partial
nephrectomy.
• Lesions that contact major vessels can
be difficult to treat with this
modality, because of the heat sink
effect INTRODUCED by circulating
blood.
 RADIOSURGERY
• The premiere tool in radiosurgery is the
gamma knife. Its principal area of
use is in neurosurgery.
• This tool allows more than 200 separate
sources of high-energy gamma
radiation, arranged in a circular
fashion, to be focused stereotactically
onto a minute area in the brain.
• This ability to destroy finite areas within
the brain has been applied to the
treatment of benign and malignant
 HYDROJET DEVICE
• The instrument cuts with high pressure of
fine water flow.
• It is commonly used in hepatic resection. It cuts
hepatic tissue while exposed intrahepatic
vessels are spared injury, which is not
possible with thermal methods.
• A higher pressure is needed to cut
fibrotic hepatic parenchyma.
• In a normal liver intrahepatic vessels of
more than
0.2mm are preserved.
• Disadvantage is formation of air bubbles which
obscure he operative field and conventional
 FLOATING BALL
(TISSUE LINK)
• This technology uses metal probe to deliver
RF energy to tissue through an intervening
layer of conductive fluid(saline) infused at the
point of tissue contact.
• Saline solution is infused by means of a ball
at he end of the device, coupling RF
energy to seal tissue.
• The presence of fluid dissipates and more
evenly distributes the heat during
dissection, resulting in tissue
temperatures of approx. 100 0C.
• At this temperature the collagen break down
causing tissue shrinkage and vessel
 REERENCE
 Sabiston Textbook of Surgery - The Biological
Basis of Modern Surgical Practice, 19th Edition
 Recommended Practices for Electrosurgery,
AORN Standards and Recommended Practices
for Perioperative Nursing. Denver, Colo.:
Association of Operating Room
Nurses;2003:237-244.
 Fortunato NM. Biotechnology: specialized
surgical equipment. In: Berry & Kohn's
Operating Room Technique. 9th ed. Mosby-
Yearbook; 2000:313-318.
 Vancallie TG. Electrosurgery: Principles and
Risks. Center for Gynecologic Endoscopy. San
Antonio, Texas:1994.
THANK
YOU