electro surgery

Electro surgery

in Gynaecology

Dept. of OBGYN M.K.C.G.Medical College Berhampur, Orissa, India

12 Oct. 02 Electro surgery in Gynaecology - Prof.S.N.Panda 2

History• Heat therapy known since antiquity• “Heat cures when everything fails” …Hipocrates. • Albucasis (980BC) used hot iron to stop bleeding.• Then followed use of electrical current on a

metallic element. • This method just burns the tissues.

• But modern electro surgery or “Surgical Diathermy” is a recent technology, which entails passage of high frequency electrical current through tissues.


History

• Earliest recorded use of this technology was by Arsenne d’ Arsonval in1893.

• However extensive use of electro surgery in brain surgery by Harvey Cushing & William T. Bovie and their publication in 1925 promoted Electrosurgery.

• They described three distinctive effects - • Desiccation• Cutting • Coagulation


Electro cautery and Electro surgery

Electro cautery • Direct current

through a high resistance metallic conductor

• It is essentially application of heat and burning of tissue

Electro surgery• High Frequency

Alt. Current through living tissue

• Manipulation of electrons to produce heat within the cells to destroy the tissue


Basics of Electricity

Two types of Current-

• Direct Current (DC)

• Alternating Current (AC)• DC flows continuously in one direction • AC flows in two directions, first increasing

to a maximum in one direction & then increasing to a maximum in the opposite direction in a sinusoidal wave form.


Basics of Electricity

• Alt.Cur. has a positive & a negative peak.


Alternating Current

• Alt.Current can be generated in Three types of wave form:-

1) Continuous / Uninterrupted / non-modulated wave form (CUT) :-

• Produced by continuous delivery of energy

2) COAG- Interrupted / Modulated / Dampened / Varied wave form:-

• when energy is delivered only 10% of the time

3) Blended wave forms:- • Produced by delivering energy at variable

intervals, which can be controlled / varied thus producing both effects


Alternating Current

1) Continuous / Uninterrupted / non-modulated (CUT) wave form:- Produced by continuous delivery of energy


Alternating Current

2) COAG- Interrupted / Modulated / Dampened / Varied wave form:-. when energy is delivered only 10% of the time


Alternating Current

3) Blended wave forms:- Produced by delivering energy at variable intervals, which can be controlled / varied thus producing both effects


The Machine (Generator)

• It produces the required type of electricity in the patient circuit by induction from the supply line.

• It has been undergoing constant improvement.• 1st. Generation- Tungsten contacts.• 2nd.Generation- Valve Generators.• 3rd. Generation- Transistor technology.• 4th. Generation- Digital Electronics technology.• Latest- Microprocessor controlled diathermy,

• User programmable, auto functions, error detection, safety alarms & cut offs.

• Constant power delivery• Under water application, soft & spray coagulation and bipolar

cut possible.


Effect of Electricity on Living Tissue

• Electrolytic Effect

• Faradic Effect

• Thermal Effect


Electrolytic Effect

• Produced by DC/ AC of very low frequency (<5kHz).

• The +ve & -ve ions in the cell move to the –ve & +ve poles.

• Electrolytic damage to the tissue.


Faradic Effect

• Produced by AC of >20 kHz

• Stimulation of nerve & muscle cells – Undesirable

• Can be avoided by using current of >300kHz


Thermal Effect

• Produced with AC >300kHz

• Tissue gets heated leading to three possibilities, depending on-• Current density, • Duration of application & • Specific resistance of the tissue.

• This is the effect for clinical use.


Thermal Effect: - Possibilities

• Electrosurgical Cutting with / without Coagulation

• Desiccation

• Coagulation / Fulguration


Electrosurgical Cutting +/- Coagulation• Very rapid heating of cells

• No time for evaporation

• Steam formation-Pressure-Cells burst

• With continuos current only cutting

• With blended current - both cutting & coagulation.


Electrosurgical Desiccation

• Tissue is gradually heated

• Water is slowly driven out

• Cell plasma coagulates

• Cut blood vessels shrink

• Bleeding stops

• Can be done with MP Ball / Needle electrode or bipolar Coagulating Forceps.


Electrosurgical Desiccation


Bipolar Diathermy

• Current flows locally through a small portion of tissue between two electrodes of the bipolar forceps


Bipolar Diathermy

• Advantages• Technique is precise & safe for the patient.• Preferred in endoscopic surgery.• Unintentional burns avoided.• Causes less disturbance to other electronic

equipments connected to the patient.

• Disadvantages• Only small amount of tissues can be handled.• Cutting possible only with microprocessor

controlled machine.


Monopolar Diathermy

• High frequency current flows from the active electrode through the patient’s body to the patient plate.

• It produces heat in the tissues proportional to the electrical resistance of the tissues and the current density.

• Fatty tissues have a high resistance.• Electrosurgical Cutting with / without Coagulation

and Desiccation / Fulguration all are possible.

• Patient plate is required.


Patient Plate

• It is the negative pole / passive electrode through which the current returns to the machine after passing through the patient.

• The current density at the patient plate is inversely proportional to the contact area.

• A 50% decrease in contact area near the patient plate will produce two fold increase in current intensity and a four fold increase of heat.


Patient Plate

• Hence the Patient plate should be as large as possible.

• It should be applied to a wide area of electrically more conductive tissues like muscles.


Patient Plate

• Current does not flow uniformly to the patient plate.

• Its density is higher at the corners and edges of the patient plate nearer to the the active electrode.

• Hence the patient plate should be placed such that the longer edge points to the active electrode.


Patient Plate

• It should make maximum and complete contact with the electrically conductive surface of the body to avoid burns.

• Metal plates not to be used. Large Silicon rubber plates should only be used.

• Simple patient plates are not so simplenot so simple..


Diathermy in Gynaecology- General Use• During surgery ( Open & Laparoscopic) for

Cutting & Haemostasis.• Cutting is more precise.• Haemostasis is better achieved.

• Can be used in LSCS. No effect on the fetus.• Take care while working near vital structures.• Apply the point first , then switch on the current.• Monopolar & or Bipolar can be used.


Diathermy in Gynaecology- Specific Use

• Benign Cervical Lesions-

• CIN (LEETZ / LEEP)-

• Tubal Sterilisation-

• Ovarian Drilling in PCOD-

• Endometriosis-

• Laparoscopic Myolysis-

• Hysteroscopic surgery- TCRE, sub mucus Myoma, Septum Resection


Electro surgery for Benign Cervical Lesions• Coagulation / Desiccation / Cutting can

be done as the case may be, using Monopolar diathermy in the following conditions.• Erosion & Chronic Cervicitis - Avoid

endocervix

• Mild degree Cx. Tears

• Amputation


Electro surgery for CIN• Known as Large Loop Excision of the

Transformation Zone (LLETZ) or LEEP (Loop Electrosurgical Excisional Procedure).

• A wire loop electrode on the end of an insulated handle is powered by an electrosurgical unit.

• The current is designed to achieve a cutting and a coagulation effect simultaneously.

• Power should be sufficient to excise tissue without causing thermal artifact.

• The procedure can be performed under local analgesia.

• Treatment success reported varies from 91% to 98%.


Electro surgery for Tubal Sterilisation

• Tubal sterilisation is usually done either by mini- laparotomy 0r laparoscopy with almost equal results.

• But laparoscopy requires more sophisticated and expensive equipment and greater skills.

• Laparoscopic sterilisation should usually be done by a single puncture and use of monopolar coagulation as described by Wheeless [Wheeless 1992].


0

5

10

15

20

25

30

35

40

clip bipolar interval ring mono PPTL overallMethod

24.8

7.5

17.7

36.5

20.1

7.5

18.5

Probability per 1000 procedures

Ten-Year Cumulative Probability of Ten-Year Cumulative Probability of Pregnancy (per 1000 procedures)Pregnancy (per 1000 procedures)

Female Sterilisation methods


Electro surgery for PCOD • For PCOD, Laparoscopic Ovarian Drilling (LOD) by

Diathermy is cost effective than Laser vaporization. • It is done by passage of 40 W current for 4 seconds in 4

places on each ovary with a monopolar needle.• Advantages of ovarian drilling-

• Sensitizes the ovary to F.S.H.• Less monitoring than Gonadotrophin therapy.• Unifollicular growth, No risk of OHSS and multiple pregnancy. • Low rate of abortion. • One treatment may result in many ovulatory cycles.• Ovulation rate 70 – 80% in failed C.C. cases, Pregnancy rate 60%

• To reduce periovarian adhesions liberal peritoneal lavage should be done. Early second look laparoscopy and adhesiolysis may be required.


Electro surgery in Endometriosis

• During surgery for endometriosis, small and multiple lesions on the peritoneum are better dealt with electrocoaglation.

• Care should be taken while working near vital structures.

• Though both monopolar and bipolar may be used, bipolar is safer and preferable.


Electro surgery for Myoma

• Myolysis - involves delivering electric current via needles (Monopolar) to a fibroid at the time of laparoscopy.

• It offers a better alternative to myomectomy with minimal blood loss to deal with myomas particularly multiple ones.


Hysteroscopic Electro surgery-

• Endometrial ablation - Tran Cervical Resection of Endometrium (TCRE), with wire loop or roller ball is a simple office procedure.• It can be the first line of surgical treatment in

Menorrhagia (DUB) and may avoid hysterectomy.

• Other hysteroscopic electrosurgical procedures are -• Electrovaporisation of sub mucus Myoma. • Septum Resection


Conclusion

• Modern diathermy is a versatile & useful surgical tool.

• Advancements in the technology has opened up many new vistas in treatment.

• Its proper & judicious use can not only benefit the patients but also will make the surgery more efficient, comfortable and simple.

• However utmost care has to be taken during its use so as to avoid catastrophes.


THANK YOUTHANK YOU

At the service of women

ELECTROSURGERY

electro surgery

Documents

current density

types of current

current returns

current int

current alt

use of electrical current

bipolardiathermy current

patient plate