electro surgery


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electro surgery

  1. 1. Electro surgery in Gynaecology Prof.Surendra Nath Panda Dept. of OBGYN M.K.C.G.Medical College Berhampur, Orissa, India
  2. 2. History <ul><li>Heat therapy known since antiquity </li></ul><ul><li>“ Heat cures when everything fails” …Hipocrates. </li></ul><ul><li>Albucasis (980BC) used hot iron to stop bleeding. </li></ul><ul><li>Then followed use of electrical current on a metallic element. </li></ul><ul><ul><li>This method just burns the tissues. </li></ul></ul><ul><li>But modern electro surgery or “Surgical Diathermy” is a recent technology, which entails passage of high frequency electrical current through tissues. </li></ul>
  3. 3. History <ul><li>Earliest recorded use of this technology was by Arsenne d’ Arsonval in1893. </li></ul><ul><li>However extensive use of electro surgery in brain surgery by Harvey Cushing & William T. Bovie and their publication in 1925 promoted Electrosurgery. </li></ul><ul><li>They described three distinctive effects - </li></ul><ul><ul><li>Desiccation </li></ul></ul><ul><ul><li>Cutting </li></ul></ul><ul><ul><li>Coagulation </li></ul></ul>
  4. 4. Electro cautery and Electro surgery <ul><li>Electro cautery </li></ul><ul><li>Direct current through a high resistance metallic conductor </li></ul><ul><li>It is essentially application of heat and burning of tissue </li></ul><ul><li>Electro surgery </li></ul><ul><li>High Frequency Alt. Current through living tissue </li></ul><ul><li>Manipulation of electrons to produce heat within the cells to destroy the tissue </li></ul>
  5. 5. Basics of Electricity <ul><li>Two types of Current- </li></ul><ul><li>Direct Current (DC) </li></ul><ul><li>Alternating Current (AC) </li></ul><ul><li>DC flows continuously in one direction </li></ul><ul><li>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. </li></ul>
  6. 6. Basics of Electricity <ul><li>Alt.Cur. has a positive & a negative peak. </li></ul>
  7. 7. Alternating Current <ul><li>Alt.Current can be generated in Three types of wave form:- </li></ul><ul><li>Continuous / Uninterrupted / non-modulated wave form (CUT) :- </li></ul><ul><ul><li>Produced by continuous delivery of energy </li></ul></ul><ul><li>COAG- Interrupted / Modulated / Dampened / Varied wave form:- </li></ul><ul><ul><li>when energy is delivered only 10% of the time </li></ul></ul><ul><li>Blended wave forms:- </li></ul><ul><ul><li>Produced by delivering energy at variable intervals, which can be controlled / varied thus producing both effects </li></ul></ul>
  8. 8. Alternating Current <ul><li>1) Continuous / Uninterrupted / non-modulated (CUT) wave form:- Produced by continuous delivery of energy </li></ul>
  9. 9. Alternating Current <ul><li>2) COAG- Interrupted / Modulated / Dampened / Varied wave form:-. when energy is delivered only 10% of the time </li></ul>
  10. 10. Alternating Current <ul><li>3) Blended wave forms:- Produced by delivering energy at variable intervals, which can be controlled / varied thus producing both effects </li></ul>
  11. 11. The Machine (Generator) <ul><li>It produces the required type of electricity in the patient circuit by induction from the supply line. </li></ul><ul><li>It has been undergoing constant improvement. </li></ul><ul><ul><li>1st. Generation- Tungsten contacts. </li></ul></ul><ul><ul><li>2nd.Generation- Valve Generators. </li></ul></ul><ul><ul><li>3rd. Generation- Transistor technology. </li></ul></ul><ul><ul><li>4th. Generation- Digital Electronics technology. </li></ul></ul><ul><ul><li>Latest- Microprocessor controlled diathermy, </li></ul></ul><ul><ul><ul><li>User programmable, auto functions, error detection, safety alarms & cut offs. </li></ul></ul></ul><ul><ul><ul><li>Constant power delivery </li></ul></ul></ul><ul><ul><ul><li>Under water application, soft & spray coagulation and bipolar cut possible. </li></ul></ul></ul>
  12. 12. Effect of Electricity on Living Tissue <ul><li>Electrolytic Effect </li></ul><ul><li>Faradic Effect </li></ul><ul><li>Thermal Effect </li></ul>
  13. 13. Electrolytic Effect <ul><li>Produced by DC/ AC of very low frequency (<5kHz). </li></ul><ul><li>The +ve & -ve ions in the cell move to the –ve & +ve poles. </li></ul><ul><li>Electrolytic damage to the tissue. </li></ul>
  14. 14. Faradic Effect <ul><li>Produced by AC of >20 kHz </li></ul><ul><li>Stimulation of nerve & muscle cells – Undesirable </li></ul><ul><li>Can be avoided by using current of >300kHz </li></ul>
  15. 15. Thermal Effect <ul><li>Produced with AC >300kHz </li></ul><ul><li>Tissue gets heated leading to three possibilities, depending on- </li></ul><ul><ul><li>Current density, </li></ul></ul><ul><ul><li>Duration of application & </li></ul></ul><ul><ul><li>Specific resistance of the tissue. </li></ul></ul><ul><li>This is the effect for clinical use. </li></ul>
  16. 16. Thermal Effect: - Possibilities <ul><li>Electrosurgical Cutting with / without Coagulation </li></ul><ul><li>Desiccation </li></ul><ul><li>Coagulation / Fulguration </li></ul>
  17. 17. Electrosurgical Cutting +/- Coagulation <ul><li>Very rapid heating of cells </li></ul><ul><li>No time for evaporation </li></ul><ul><li>Steam formation-  Pressure-Cells burst </li></ul><ul><li>With continuos current only cutting </li></ul><ul><li>With blended current - both cutting & coagulation. </li></ul>
  18. 18. Electrosurgical Desiccation <ul><li>Tissue is gradually heated </li></ul><ul><li>Water is slowly driven out </li></ul><ul><li>Cell plasma coagulates </li></ul><ul><li>Cut blood vessels shrink </li></ul><ul><li>Bleeding stops </li></ul><ul><li>Can be done with MP Ball / Needle electrode or bipolar Coagulating Forceps. </li></ul>
  19. 19. Electrosurgical Desiccation
  20. 20. Bipolar Diathermy <ul><li>Current flows locally through a small portion of tissue between two electrodes of the bipolar forceps </li></ul>
  21. 21. Bipolar Diathermy <ul><li>Advantages </li></ul><ul><ul><li>Technique is precise & safe for the patient. </li></ul></ul><ul><ul><li>Preferred in endoscopic surgery. </li></ul></ul><ul><ul><li>Unintentional burns avoided. </li></ul></ul><ul><ul><li>Causes less disturbance to other electronic equipments connected to the patient. </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Only small amount of tissues can be handled. </li></ul></ul><ul><ul><li>Cutting possible only with microprocessor controlled machine. </li></ul></ul>
  22. 22. Monopolar Diathermy <ul><li>High frequency current flows from the active electrode through the patient’s body to the patient plate. </li></ul><ul><li>It produces heat in the tissues proportional to the electrical resistance of the tissues and the current density. </li></ul><ul><li>Fatty tissues have a high resistance. </li></ul><ul><li>Electrosurgical Cutting with / without Coagulation and Desiccation / Fulguration all are possible. </li></ul><ul><li>Patient plate is required. </li></ul>
  23. 23. Patient Plate <ul><li>It is the negative pole / passive electrode through which the current returns to the machine after passing through the patient. </li></ul><ul><li>The current density at the patient plate is inversely proportional to the contact area. </li></ul><ul><li>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. </li></ul>
  24. 24. Patient Plate <ul><li>Hence the Patient plate should be as large as possible. </li></ul><ul><li>It should be applied to a wide area of electrically more conductive tissues like muscles. </li></ul> 
  25. 25. Patient Plate <ul><li>Current does not flow uniformly to the patient plate. </li></ul><ul><li>Its density is higher at the corners and edges of the patient plate nearer to the the active electrode. </li></ul><ul><li>Hence the patient plate should be placed such that the longer edge points to the active electrode. </li></ul> 
  26. 26. Patient Plate <ul><li>It should make maximum and complete contact with the electrically conductive surface of the body to avoid burns. </li></ul><ul><li>Metal plates not to be used. Large Silicon rubber plates should only be used. </li></ul><ul><li>Simple patient plates are not so simple . </li></ul>
  27. 27. Diathermy in Gynaecology- General Use <ul><li>During surgery ( Open & Laparoscopic) for Cutting & Haemostasis. </li></ul><ul><ul><li>Cutting is more precise. </li></ul></ul><ul><ul><li>Haemostasis is better achieved. </li></ul></ul><ul><li>Can be used in LSCS. No effect on the fetus. </li></ul><ul><li>Take care while working near vital structures. </li></ul><ul><li>Apply the point first , then switch on the current. </li></ul><ul><li>Monopolar & or Bipolar can be used. </li></ul>
  28. 28. Diathermy in Gynaecology- Specific Use <ul><li>Benign Cervical Lesions- </li></ul><ul><li>CIN (LEETZ / LEEP)- </li></ul><ul><li>Tubal Sterilisation- </li></ul><ul><li>Ovarian Drilling in PCOD- </li></ul><ul><li>Endometriosis- </li></ul><ul><li>Laparoscopic Myolysis- </li></ul><ul><li>Hysteroscopic surgery- TCRE, sub mucus Myoma, Septum Resection </li></ul>
  29. 29. Electro surgery for Benign Cervical Lesions <ul><li>Coagulation / Desiccation / Cutting can be done as the case may be, using Monopolar diathermy in the following conditions. </li></ul><ul><ul><li>Erosion & Chronic Cervicitis - Avoid endocervix </li></ul></ul><ul><ul><li>Mild degree Cx. Tears </li></ul></ul><ul><ul><li>Amputation </li></ul></ul>
  30. 30. Electro surgery for CIN <ul><li>Known as Large Loop Excision of the Transformation Zone (LLETZ) or LEEP (Loop Electrosurgical Excisional Procedure). </li></ul><ul><li>A wire loop electrode on the end of an insulated handle is powered by an electrosurgical unit. </li></ul><ul><li>The current is designed to achieve a cutting and a coagulation effect simultaneously. </li></ul><ul><li>Power should be sufficient to excise tissue without causing thermal artifact. </li></ul><ul><li>The procedure can be performed under local analgesia. </li></ul><ul><li>Treatment success reported varies from 91% to 98%. </li></ul>
  31. 31. Electro surgery for Tubal Sterilisation <ul><li>Tubal sterilisation is usually done either by mini- laparotomy 0r laparoscopy with almost equal results. </li></ul><ul><li>But laparoscopy requires more sophisticated and expensive equipment and greater skills. </li></ul><ul><li>Laparoscopic sterilisation should usually be done by a single puncture and use of monopolar coagulation as described by Wheeless [Wheeless 1992]. </li></ul>
  32. 32. Female Sterilisation methods Method 24.8 7.5 17.7 36.5 20.1 7.5 18.5 Probability per 1000 procedures Ten-Year Cumulative Probability of Pregnancy (per 1000 procedures)
  33. 33. Electro surgery for PCOD <ul><li>For PCOD, Laparoscopic Ovarian Drilling (LOD) by Diathermy is cost effective than Laser vaporization. </li></ul><ul><li>It is done by passage of 40 W current for 4 seconds in 4 places on each ovary with a monopolar needle. </li></ul><ul><li>Advantages of ovarian drilling- </li></ul><ul><ul><li>Sensitizes the ovary to F.S.H. </li></ul></ul><ul><ul><li>Less monitoring than Gonadotrophin therapy. </li></ul></ul><ul><ul><li>Unifollicular growth, No risk of OHSS and multiple pregnancy. </li></ul></ul><ul><ul><li>Low rate of abortion. </li></ul></ul><ul><ul><li>One treatment may result in many ovulatory cycles. </li></ul></ul><ul><ul><li>Ovulation rate 70 – 80% in failed C.C. cases, Pregnancy rate 60% </li></ul></ul><ul><li>To reduce periovarian adhesions liberal peritoneal lavage should be done. Early second look laparoscopy and adhesiolysis may be required. </li></ul>
  34. 34. Electro surgery in Endometriosis <ul><li>During surgery for endometriosis, small and multiple lesions on the peritoneum are better dealt with electrocoaglation. </li></ul><ul><li>Care should be taken while working near vital structures. </li></ul><ul><li>Though both monopolar and bipolar may be used, bipolar is safer and preferable . </li></ul>
  35. 35. Electro surgery for Myoma <ul><li>Myolysis - involves delivering electric current via needles (Monopolar) to a fibroid at the time of laparoscopy. </li></ul><ul><li>It offers a better alternative to myomectomy with minimal blood loss to deal with myomas particularly multiple ones. </li></ul>
  36. 36. Hysteroscopic Electro surgery- <ul><li>Endometrial ablation - Tran Cervical Resection of Endometrium (TCRE), with wire loop or roller ball is a simple office procedure. </li></ul><ul><ul><li>It can be the first line of surgical treatment in Menorrhagia (DUB) and may avoid hysterectomy. </li></ul></ul><ul><li>Other hysteroscopic electrosurgical procedures are - </li></ul><ul><ul><li>Electrovaporisation of sub mucus Myoma. </li></ul></ul><ul><ul><li>Septum Resection </li></ul></ul>
  37. 37. Conclusion <ul><li>Modern diathermy is a versatile & useful surgical tool. </li></ul><ul><li>Advancements in the technology has opened up many new vistas in treatment. </li></ul><ul><li>Its proper & judicious use can not only benefit the patients but also will make the surgery more efficient, comfortable and simple. </li></ul><ul><li>However utmost care has to be taken during its use so as to avoid catastrophes. </li></ul>
  38. 38. THANK YOU  At the service of women ELECTROSURGERY