Tools in Hysteroscopic Surgery

1. A. Prof. Dr Aisha Mohamed El-Bareg
MBBS, DGO, MMedSci (ART, Nottingham University-
UK), ABOG, (MD), PhD (Manchester University-UK)
Consultant Obstetrician & Gynecologist
With subspecialty in Endoscopic Surgery ,Reproductive
& Stem Cell Medicine
Al-Amal Hospital for Obstetrics & Gynaecology,Infertility
treatments and Genetic Research
Faculty of Medicine , Misurata University /Libya

2. Electro-Surgical Unit (ESU)
 Electrosurgical units are the most common
type of electrical equipment in the operating
room.
 A basic understanding of electricity is needed
to safely apply electrosurgical technology for
patient care.
 Electrothermal injury may result from direct
application, insulation failure, direct coupling,
capacitive coupling.

3. Dr. William T. Bovie
• The conception of electrosurgery began in the
early 19th century when the French physicist
Becquerel first used electrocautery. Rather than
using boiled oil to achieve hemostasis, he
passed direct current through a wire thereby
heating it and effectively cauterizing tissue
upon contact.
History
• Bovie made first electrosurgical
unit in 1926.
• In 1881, morton: electric current in 100,000
Hz does not produce shock, Arsonoval
pioneered the use of alternating current.

4.  The terms electrocautery and electrosurgery
are frequently used interchangeably; however,
these terms define two distinctly different
modalities.
 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 desired effect..
Electrocautery IS NOT Electrosurgery

5. Electro-surgery
 Involves using a high-frequency electric
current to cut tissue and coagulate bleeding.
 The flow of electricity requires a complete
pathway (circuit).

6.  The rapidity with which the direction of current
flow changes per unit of time is referred to as
frequency, and is measured in Hertz (Hz).
 One complete cycle per second is one Hz (one
oscillation/second). If a current alters polarity
one million times per second, it is a one
megahertz (MHz) current.
Electro-surgery

7.  Standard electrical current has frequency of
60 Hz.
 Nerve and muscle stimulation (Depolarization)
ceases at frequencies above 100,000 Hz
(100kHz).
 An electrosurgical generator takes 60 Hz
current and increases its frequency to over
200,000 Hz (Radio-Frequencies) can pass
through the patient with out neuromuscular
stimulation and no risk of electrocution.
Electro-surgery

10. There are two kinds of current
Direct current Alternate current

11. 1. Direct current:
 is constant, never change in direction
(polarity) or magnitude.
 Is the type produced by the batteries.
 Not used in electro surgery because of its
tendency to produce depolarization of neural
and muscular tissue
Types of current waveforms

12. 2. Alternate current, its direction (polarity)
changes (alternate).
 This type is similar to that which comes from
the electrical wall outlet.
 Alternate current is characterized by a typical
sinusoidal shape, namely with consecutive
waves reaching a peak, first in one direction
and then in the opposite one.

13. A cut current (cut):
A pure sine wave. supplies high frequency
current, non interrupted, with low voltage.
Types of Alternate waveforms

14. A clot current (coagulation) supplies an
interrupted wave current, with high voltage; the
electro-generator supplies power only in 6% of
the time (on) while in the remaining 94% the
generator does not produce power (off) allowing
the electrode cool.
Types of current waveforms

15. A blended current is just a continuous cut
current which is interrupted by creating several
on-off cycles. A modulation of these two kinds.
Types of current waveforms

17. An electric circuit always requires two poles
Electro-surgical modes
divided into two kinds:
Monopolar Bipolar

19. Monopolar mode
The current flow generated by the device passes
through an "active" electrode, which can have
several shapes and sizes, crosses the patient’s
body and returns to the electro-generator through
a suitably sized "passive" electrode which is
normally applied on the skin surface.

20. Bipolar mode
The electron flow passes through a forceps jaw,
crosses the tissue interposed in the forceps and
returns to the electro-generator through the
second jaw. Electrical current is confined to the
tissue between the bipolar forceps.

21. A bipolar circuit.
Unipolar circuit.
Bipolar circuit.

23. Unipolar Mode vs Bipolar Mode
 In bipolar mode, the flow of electricity is entirely
contained between the two electrodes and is
thus always under the direct vision of the
surgeon.
 In Unipolar mode, the current passes through
numerous layers of tissue, outside the
surgeon’s vision before returning to the
generator. Therefore, the risk of iatrogenic
burns either due to direct contact with
instrument or faults in insulation or diffusion of
electrical current is more.

24.  Bipolar mode, The risk of interference with
other electronic devices (ECG, pace maker,
etc) which are also connected to the patient is
virtually nil.
 Bipolar mode, electrical stimulation of
peripheral nerves, such as obturator nerve, is
reduced.
 Bipolar mode, cleaner and sharper cut with
less thermal damage to the surrounding tissue.
Also useful in histopathological interpretation.
Unipolar Mode vs Bipolar Mode

25.  Bipolar Mode, The temperature of the
surrounding tissue between 40⁰-70⁰ C, while
Unipolar current temperature is up to 400⁰C,
resulting in significant deep surrounding tissue
damage.
 Bipolar mode, more efficacious coagulation.
 Bipolar mode, reduce the risk of intravasation
damage as the distension medium used is
physiological saline solution.
Unipolar Mode vs Bipolar Mode

26. REM System(renewable energy
management systems)
 Most ESU units on the market today have
REM technology.
 REM system continually monitors the heat
build-up under the grounding pad
 If the system detects excess heat build-up it
will shut off the current flow to prevent patient
injury

27. Patient Return Electrode Site Selection
• Follow manufacturer’s
written instruction.
• Well vascularized
muscle area.
• Convex area.
• Close to surgical site.

28. Patient Return Electrodes Site Selection
Prostheses Bony prominences
Scar tissue Hair

29. Patient Return Electrode Site
Preparation
Protect return electrode
from fluid invasion
Do not use flammable
agents for PRE site
preparation

30. Displacement of return electrode

31. Active Electrode
 Active electrode MUST be in
a non-conductive holster
when not in use.
 Electrode that does not fit
holster should be placed in a
designated site with tip away
from flammable material.
 Active electrode tips should
be securely seated into the
hand piece

32. Active Electrodes
Use a coated electrode to easily remove
eschar buildup on electrode tip.
“Frequent cleaning of the
electrode tip is recommended.”

33. Radiofrequency Current
Leakage
 Active electrode cords
should not be wrapped
around metal instruments
 Active electrode and
other electrical cords
should not be bundled
together

34. General Safety Precautions
Test alarm systems Set activation tone
to audible level
Confirm power settings
Plug accessories into
correct receptacles

36. Complications
 Explosion
 Burns
 Lap.surgery

37. Explosion
 Sparks from diathermy can ignite any volatile
or gases or fluid within the theatre.
 Alcohol based skin preparation can catch fire if
they are allowed to pool or around the patient.

38. Burns
 Faulty application of the
indifferent electrode with
inadequate contact area.
 Patient being earthed by
touching any metal object.
 Faulty insulation of
diathermy leads.
 Inadvertent activity such
as accidental activation of
foot pedal.

43. Types of Bipolar electrode
 Spring, twizzle and ball electrode.
 Spring tip for haemostatic vaporization of large
areas.
 Ball tip for precise vaporization.
 Twizzle tip for haemostatic resection and
morcellation of tissue.
 Cutting loop similar to traditional resectoscopy

44. Vaporizing electrodes
 It allows vaporization of tissue
 Cuts and desiccates the tissue
 Instantaneous tissue vaporization eliminates
resection chips thus permitting continuous
visualization of tissue effect.
 Cutting power and coagulation is better due to
plasma effect.

45.  Vision during resection is not disturbed.
 A vaporizing electrode may prevent significant
blood loss during myoma resection by sealing
blood vessels as the tissue is vaporized.
Vaporizing electrodes

46. Uses of vaporizing electrodes
 Removal of submucous fibroids
 Transection of intrauterine septa
 Removal of polyps
 Endometrial Ablation
 Transection of intrauterine adhesions

47. Distension media
 For monopolar- use electrolyte free distension
media like sorbitol, glycine 1.5% or mannitol.
 Bipolar resectoscope is generally designed that
even in the electrolyte rich media like normal
saline the circuit is completed.
 Biggest advantage: The risk of hyponatremia is
obviated

48.  In Bipolar- normal saline used has ion
concentrations similar to human plasma which
reduces electrolyte changes and hyponatremia.
 Fluid deficits must still be monitored so they do
not exceed 2,000 mL
Distension media

49. Complications of Monopolar
Resectoscope
 Active electrode injury-perforation of uterus,
bowel, bladder, Other vascular structure.
 Current Diversion: burns to cervix ,vagina, or
vulva.
 Damage of electrode insulation
 Loss of contact with external sheath and
cervix –burns
 Direct coupling of current- if tissue is stuck

50. Comparision of Monopolar and Bipolar
resection of myoma (Romer T)
 Preferred Indications
 Myoma Grade 2 and large
myoma(>4cm)
 Advantage
 Less complications
 rarely second surgery
 Results 60% after first surgery with
monopolar,95% with bipolar.

51. Conclusions
 Bipolar has biggest advantage that it can be
done with NS or RL without the fear of life
threatening complication like cerebral edema.
 The main evolution with Bipolar is shifting from
inpatient procedures to the office leading to
saving of medical costs and making see and
treat facility.
 Excellent hemostasis in vapour cut mode
 Total vaporization of myoma avoids the
process of removing the chips from field of
vision.

52.  The bipolar hysteroscopic system has
eliminated the need to use hypotonic solutions
as irrigation medium, with its life-threatening
complications. When limiting normal saline
solution to 2 L, no serious complications
associated with irrigation medium are
expected. Therefore, we believe that when
available, the bipolar system should be
preferred.
Conclusions