Basic electrosurgery

1. Medtronic
ELECTROSURGERY
By: Mojtaba Khojaste

2. Medtronic
KEY REQUIREMENT OF SURGERY IS TO CONTROL
BLOOD LOSS

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WHAT IS ELECTRICITY
• Electricity can be created by forcing electrons to flow
from atom to atom.

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ELECTRICAL CURRENT

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ELECTRICAL CIRCUIT
1 2
Complete Circuit
3
4 Current
1
2
3
4
5
5

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RESISTANCE IN DIFFERENT TISSUES

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RESISTANCE IN DIFFERENT TISSUES

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RESISTANCE IN DIFFERENT TISSUES

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RESISTANCE IN DIFFERENT TISSUES

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RESISTANCE IN DIFFERENT TISSUES

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PRIMARY RULES : ELECTRICITY ALWAYS
• Flows to ground
• Follow path of least resistance

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ELECTROSURGERY TO CONTROL
BLOOD LOSS

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CAUTERISE
• Application of heat into tissue
• Using different instruments to get
a different effect
• What would you use each of the
different instrument for?

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Voltage
Time
+
-
DIRECT & ALTERNATING CURRENT
Reference
+
-
Direct Current
Alternating Current - Electrosurgery
Voltage
Time
Reference
- Electrocautery

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TYPES OF ELECTROSURGICAL
GENERATORS
Grounded Systems
Isolated Systems

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GROUNDED SYSTEMS

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WHY ALTERNATE SITE INJURIES
OCCUR
 Alternate site injury resulted
from the use on a ground
reference generator
 The use of isolated generators
has minimized this risk
 Still a risk when using large
capacitive patient return
electrodes

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ALTERNATE SITE INJURIES

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ISOLATED SYSTEM

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MAXIMUM LEAKAGE CURRENT ALLOWED
• High Voltage – High Leakage
• Return current may exit in ways other than the patient – may
cause a burn .
• Safety Standard is :
► 100 KHZ – 150000 Microamperes
In Isolated ESU , the leakage is the RF current that regains its ground reference

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ELECTROSURGICAL TISSUE EFFECT
• Electrosurgery : 2 Types : Bipolar and Monopolar
• Monopolar - Cut & Coagulate
• Bipolar – Coagulate

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MONOPOLAR ELECTROSURGERY
Active electrode at surgical site
Return electrode at another site
Current flows through
the body between the electrodes
Voltage ranges:
• Cut : 1350 - 4000 V
• Blend : 2975 - 4500 V
• Coag : 3000 - 9000 V

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THE ELECTROSURGICAL EFFECT IS
INFLUENCED BY VARIABLES
1. Contact Time/Speed of movement
2. Power settings of generator
3. Type of electrode used (Current Density)
4. Generator Mode Cut/Coag
5. Tissue impedance (inc Distance from Active to Return)

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1. Contact Time/Speed of movement

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1. Contact Time/Speed of movement
The longer electrosurgery current is applied
The more potential for thermal spread
Time – The length of time that the surgeon uses the active electrode
determines the amount of tissue effect. Too long an activation time will
produce wider and deeper tissue damage. Too short an activation time will
not produce the desired tissue effect.

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2. Power settings of generator
 Impedance effects power setting:
 Muscular patients of weight and height in proper
portions require lower power settings than obese
or emaciated patients
 Placing the patient return electrode close to the
surgical site enables the use of lower power
settings because impedance between the two
sites is less
Use the lowest possible setting to achieve the desired
surgical effect!!!
See manufacturer’s users’ manual for
power setting guidelines

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BENEFITS OF LOWER POWER SETTINGS
Burns, patient injuries are proportional to power settings LOWER is BETTER
 Less thermal spread ‫ــ‬ Better patient recovery
 Less arcing – Less tissue damage
 Less tissue damages – Better patient recovery
 Less smoke – Operator protection & save time
 Less charring tissues – Safe

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3. Type of electrode used (Current Density)
1. Electrode size is another variable.
2. The smaller the electrode used, the higher the
current concentration. A small active electrode ,
such as a needle tip, can achieve the tissue effect,
even though the power setting is reduced.
3. When changing the electrode to a different
configuration, the surgeon should determine if
the power needs to increase or decrease,
depending on the size and configuration of the
electrode.

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3. Type of electrode used (Current Density)
The more concentrated the current, the greater the potential for a burn.

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4. Generator Mode or waveform
Generators are modulated to deliver different waveforms
or, electrosurgical modes
 CUT mode is designed to divide tissue with little or no
hemostasis
 BLEND uses an interrupted waveform to achieve
clinical effect
 COAG is a generator modified waveform with an
interrupted duty cycle of 4.5-6.5%
 Called fulgeration , the sparking from the
coagulation waveform coagulates the tissue over a
wide area

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WAVE FORMS
Pure CutPure Cut Blend Cut Desiccate Fulgurate
100 % ON
Less Volts
60 % ON – 40 % OFF
Higher Voltage
Very High Voltage
to push thru Air

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5. Tissue impedance

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ELECTROSURGERY
pure Blend fulguration dessiccation
Cut COAGULATION

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PURE CUT
Cells Explosion

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Energy
Cells Expand thru
Increase in Pressure
Exploded Cells
Electrodes preferred for Cutting : Needle / Fine Needle/ Loop
CUT

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COUAGOLATION
Coagulated Cells
Energy
Dehydration thru
heating
Lower current density causes
dehydration and shriveling of the
cells. Intracellular fluid evaporates
BLADE/ BALL/
FORCEPS

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COUAGOLATION

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Difference between the Cut , Blend & Coag
Thermal Spread/CharringLow High
Blend CoagCut

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CREST FACTOR
Crest Factor =
𝑉 𝑝𝑒𝑎𝑘
𝑉 𝑅𝑀𝑆
For ideal sine wave , CF : 1.414

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Waveforms
50% on
50% off
40% on
60% off
25% on
75% off
Pure Cut and
Bipolar Blend 1 Blend 2 Blend 3 Pure Coag
100% on 6% on
94% off
?
??
With blend, we are raising the ___________
but we are decreasing the ______ _______ .
Blend is derived from the Cut waveform.
voltage
duty cycle
What is the difference between the Pure Cut and Pure Coag waveforms?

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SPRAY

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SPRAY MODE
ForceTriad™ energy platform
Coag Duty Cycles:
Fulgurate – 6.5%
Spray – 4.6%
Fulguration (lightning) is used to
control bleeding. Low (6%) duty
cycle, but high voltage. The tip of
the electrode should be held
slightly over the tissue.

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MONOPOLAR ELECTROSURGICAL
PENCILS
Footswitching
Pencil
Rocker Switch
Pencil
Two-Button
Pencil
Three-Button
Pencil

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Brûlure sous la plaque

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SINGLE PLATE
ALARME

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DOUBLE PLATE
COURANT HF

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Generator
Circui
t
Patient Jack
Active Jack
CONTACT QUALITY MONITORING
SYSTEM

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Interrogation
Current
CONTACT QUALITY MONITORING
SYSTEM IN STATE OF ALARM

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insuffisant contact
REM
(Return Electrode
Monitoring)
REM
Measures the change in impedance at the skin level of the patient ..
When the change is risky – Alarm

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• No Plate Burns
• Generator More Efficient
• 100,000,000 cases without any incidence
RETURN ELECTRODE MONITORING

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ADAPTIVE REM™ TECHNOLOGY
5 Ω 135 Ω
70 Ω
Standard range of safe
resistance
60 Ω
Baseline
Resistance
84 Ω
40% increase
in resistance
50 Ω
Baseline
Resistance
70 Ω
40% increase
in resistance
Decreased resistance changes the
baseline, so the 40% upper limit changes
as well.
Decreased resistance changes the
baseline

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ELECTROCAUTRY SORES :
1. Small Area
2. Sharp Surrounding
3. Very Deep (third degree)
4. Happens Immediately

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BIPOLAR ELECTROSURGERY
• Active and return electrodes within the
instrument;
no patient return electrode (pad) required
• Current flow is confined to tissue between
electrodes
• Relatively low voltage (300V – 1200V)
• Used for delicate tissue and confined
surgical sites:
• Laparoscopy
• Spinal
• Neurosurgery
• Ophthalmology
Current between
the tines

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BIPOLAR ELECTROSURGERY

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TYPICAL BIPOLAR INSTRUMENTS
Tines

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CONTROL OF BLEEDING USING
MONOPOLAR AND BIPOLAR ES
 Vessel size must be small (< 2 mm)
 Low burst pressure
 Sufficient coagulation dependent on
 technique and application time
 Lateral thermal spread can be large
 Small vessels can be transected
 unintentionally

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ELECTROSURGERY HAZARDS

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ELECTROSURGERY HAZARDS
Hazards In Laparotomy surgeries:
1) The Leakage Current
2) The place of plate
3) Open circuit activation
4) Using Spray Mode in pick ups
5) Electrosurgical Smoke
Hazards in Laparoscopic
Surgeries:
1) Direct Coupling
2) Insulation Failure
3) Capacitive Coupling
4) Residual Heat
5) Electromagnetic Interface
6) Electrosurgical Smoke

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Hazards In Laparotomy surgeries:
The Leakage Current

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Hazards In Laparotomy surgeries:
The place of plate
Muscular
No Hair
No Scar
Optimum 50 cm
Direction

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Hazards In Laparotomy surgeries:
Open circuit activation

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Hazards In Laparotomy surgeries:
Using Spray Mode in pick ups

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Hazards In Laparotomy surgeries:
Electrosurgical Smoke
BIOLOGICAL CONTAMINANTS
 Particles
 Carbonized tissue
 Blood
 Potential virus and bacteria
 Steam
CHEMICAL CONTAMINANTS
 Toxins (carcinogens)
 Acrolein
 Benzene
 Formaldehyde
 Toluene
 Polycyclic aromatic hydrocarbons

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RapidVac™ SMOKE EVACUATION
SYSTEM
•Designed to:
• Capture particulates and
absorb smoke and odors
• Improve visibility
• Reduces potential health
hazards
•Used in both open and
laparoscopic procedures

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PENCIL WITH AccuVac™ ATTACHMENT

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Hazards in Laparoscopic Surgeries:
Direct Coupling

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Hazards in Laparoscopic Surgeries:
Insulation Failure

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Hazards in Laparoscopic Surgeries:
Capacitive Coupling

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Hazards in Laparoscopic Surgeries:
Residual Heat

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Hazards in Laparoscopic Surgeries:
Electromagnetic Interface

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Hazards in Laparoscopic Surgeries:
Electrosurgical Smoke

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Valleylab History

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Valleylab HISTORY OF INNOVATION
1967 – Valleylab Founded
1981 – REM™ technology
1995 – Instant Response™ Technology
1968 – Portable Solid State Generator
1970 – Isolated Generators
1973 – Disposable Pencil
1976 – Handswitching Pencil
1991 – Four Function Lap Handpiece
1994 – Clinical Hotline
2007 ‫ــ‬Tissue sensing technology
2007 ‫ــ‬ Third mono polar mode (Valleylab mode)
2007- Closed-loop coag

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Force 2 in 1986

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Old Technologies
No Instant Response

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Old Technologies
No Instant Response

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Old Technologies
No Instant Response

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Old Technologies
No Instant Response

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Tissue Response Technology PER = 98
Conventional Technology PER = 61
Watts
Ohms
Cut set at 40 Watts

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Instant Response
Technology
(Tissue Response)
Founded in 1995

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MEASUREMENT
200 times
PER SEC
REGULATIONS
Output
VARIATIONS
Presets
Instant Response Technology

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Instant Response Technology

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Instant Response Technology

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Instant Response Technology

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Instant Response Technology

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Instant Response Technology
CONSTANT
POWER
Power
IMPEDANCE

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Tissue Response Technology PER = 98
Conventional Technology PER = 61
Watts
Ohms
Cut set at 40 Watts

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Clinical Benefits of IRT™
Reduced lateral thermal spread Fewer power setting changes Less video
interference Minimized sparking

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LigaSure™ VESSEL SEALING SYSTEM

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LigaSure™ VESSEL SEALING SYSTEM
LigaSure™ is a unique combination of pressure and
energy used to seal vessels, tissue bundles, and
lymphatics up to and including 7 mm in diameter to
create a permanent, flexible seal that can withstand at
least 3 times systolic pressure.

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LigaSure™ : SYSTEM OPERATION

95. MedtronicCovidien | | Confidential Formerly Tyco Healthcare

96. MedtronicCovidien | | Confidential Formerly Tyco Healthcare

97. MedtronicCovidien | | Confidential Formerly Tyco Healthcare

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BIPOLAR COAGULETED VESSEL
CHARACTERISTICS
 Open Loop System – No feedback
 Relies on tissue shrinking and proximal Thrombus for Ligation
 Lumen Still Apparent
 Tissue Damage determined by Power Setting , activation time and shape of
Power Curve
Vessel Sealing
Intimal walls of vessel fused,
complete lumen occlusion
Traditional Bipolar
Vessel shrinkage lumen partially
open and a thrombus is needed
for vessel occlusion

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ForceTriad™ ENERGY PLATFORM
 Third monopolar mode (Valleylab mode)
 TissueFect™ sensing technology
 Closed-loop Coag
 Tissue fusion technology

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Valleylab Mode Key Message
The Valleylab Mode provides an
optimal combination of monopolar
hemostasis and division while using a
lower power setting resulting in less
char, less thermal spread, less arcing
and smoother passage through tissue
than a traditional coagulation mode.

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Third monopolar mode (Valleylab mode)
Blue
Yellow
Clear
Coagulation
Dissection with hemostasis
Cut
Cuts faster, bleeds
less

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Third monopolar mode (Valleylab mode)
Teflon coted
blead
3 Button
Power control from sterile field

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TISSUEFECT™ SENSING TECHNOLOGY
 Senses tissue impedance
 Decisions about tissue and output
made every 300 milliseconds, or 3,333
times per second
 Lower power settings and voltages in
allmodes reduces patient injury risk
 Closed-loop control Coag

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A CLOSER LOOK AT TISSUEFECT™
SENSING TECHNOLOGY
• TissueFect™ is an improved computer program, which senses tissue
impedance and adjusts the energy to achieve the desired tissue effect
• Power behind all the ForceTriad™ energy platform system functions
• Designed to precisely manage energy delivery over a wide range of tissue
impedances in the human body
• Provides more thorough desiccation of tissue utilizing a more gentle energy
delivery than the original LigaSure™ generator

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CLINICAL BENEFITS OF TISSUEFECT
SENSING ENERGY
 - Reduced lateral thermal spread
 - Fewer power setting adjustments
 - Less video interference
 -Minimized sparking
 -Only contact quality monitoring

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Feedback Speed:
TissueFect™ Tissue Sensing Technology
IRT- Force FX TissueFect Technology Force Triad
200 X / SEC
3333 DEC / SEC

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MONOPOLAR CLOSED-LOOP COAG
The ForceTriad™ energy platform is the first
system to use closed-loop control in Coag
 Provides consistent energy delivery across a
wide range of tissue impedance
 Rapid initiation of argon beam
 More controlled delivery of coagulation
energy
Balanced waveform output produces
consistent spark initiation
Force FX™
generator
ForceTriad™
energy platform

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Waveform
Compariso
n
Coagulatio
n mode
TISSUEFECT™SENSINGTECHNOLOGY

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COAG POWER CURVE COMPARISON

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CLINICAL RESULTS OF TISSUE FUSION
• Reduced thermal spread
• Can reduce blood loss
• Less risk of retained needles
• Fewer needlestick injuries
• No dislodged clips
• No foreign material left behind
• Tissue in normal anatomical position

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Monopolar Bipolar Tissue Fusion x 2
♦ Combined Energy Sources
♦Easy to understand and use

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Special Features
For ForceTriad Energy Platform
• 3333 decisions per second
• Less Necrosis
• Less Thermal Effect
• Less Power Setting
• Up to 3times fast LigaSure
• Computerized System
• Touch screen with
• Friendly operation
• Valleylab Mode

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Sonicision™
Cordless Ultrasonic Dissection System

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Introducing Sonicision™
The industry’s first cordless ultrasonic dissection device
Cordless
Improves freedom of movement and mobility
Intuitive
One button with two power settings means
eyes can stay on the field
Efficient
Quick and simple set up
R0024175

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Energy Market Landscape
R0024175

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NEW PRODUCT SEGMENTATION
Dissection Multifunction Ligation
 Urology
 General
LigaSure™ 5 mm
 GYN
 Colorectal
Sonicision™
 GYN
 Urology
 General
 Upper G.I.
 Bariatric
 Colorectal
LigaSure Advance™
Pistol Grip
 Colorectal
 GYN
 Bariatric
 L. Nephrectomy
 L. Splenectomy
R0024175

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Parts R0024175Reusable Generator
• Low temperature hydrogen peroxide gas
plasma sterilization (i.e. STERRAD™*)
Reusable Battery
• Low temperature hydrogen peroxide gas
plasma sterilization (i.e. STERRAD™*)
Ultrasonic Dissector
• Single patient use
Dual-Mode Energy Button
Indicator
LED
Torque Wrench
Audio
Indicator
SONICISION PARTS

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ASSEMBLY STEPS
Step 1 - Attach and Torque
Generator
1. Slide the generator into the
opening of the ultrasonic dissector
and hand tighten clockwise while
holding the shaft rotation wheel.
R0024175
Shaft Rotation
Wheel
Torque Knob
Generato
r

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Step 2 - Attach Battery
1. Orient battery pack as shown.
2. Swing the battery forward and
snap into place.
When properly assembled, a
series of tones sound and the LED
on the generator illuminates green.
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ASSEMBLY STEPS

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NEW LigaSure™
New Vessel Sealing System Model
LS10

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‫صف‬‫شکست‬‫ضریب‬ ‫ای‬‫ر‬‫دا‬‫ر‬
‫تا‬3‫سیستو‬ ‫فشار‬‫ابر‬‫ر‬‫ب‬‫لیک‬
(‫تا‬400‫جیوه‬‫میلیمتر‬)
‫تکنولوژی‬ ‫ای‬‫ر‬‫دا‬Tissue Effect Plus‫و‬ ‫شناسایی‬ ‫در‬ ‫هوشمندی‬ ‫باعث‬ ‫که‬
‫بطوریک‬ ‫بوده‬ ‫دستگاه‬ ‫در‬‫خودکار‬ ‫بطور‬ ‫انرژی‬ ‫تنظبم‬ ‫و‬‫هدف‬ ‫بافت‬ ‫ارزیابی‬‫ان‬‫ز‬‫می‬ ‫ه‬
‫ارتی‬‫ر‬‫ح‬ ‫پخش‬(Thermal Spread)‫حداکثر‬‫جانبی‬‫بافتهای‬ ‫به‬1‫هر‬ ‫ای‬‫ر‬‫ب‬ ‫متر‬ ‫میلی‬
‫میباشد‬ ‫هندپیس‬ ‫مدل‬.
‫ب‬‫کارکرد‬ ‫قابلیت‬‫ا‬
‫ن‬‫مدر‬‫هندپیسهای‬
‫و‬ ‫کمپانی‬
‫قدیم‬‫هندپیسهای‬‫ی‬
‫کانکتور‬ ‫ای‬‫ر‬‫دا‬
‫هوشمند‬
(Smart
Connector)
‫و‬‫شناسایی‬ ‫جهت‬
‫تشخیص‬
‫هندپیسهای‬
‫مختلف‬
‫و‬ ‫ی‬‫بصر‬‫ل‬‫کنتر‬ ‫ای‬‫ر‬‫دا‬
‫نمایش‬ ‫و‬‫خودآموز‬
‫ای‬‫ر‬‫ب‬ ‫ساده‬‫اطالعات‬
‫عیب‬ ‫و‬ ‫درک‬،‫ی‬‫یادگیر‬
‫دستگاه‬ ‫یابی‬.
‫د‬‫عروق‬ ‫انسداد‬ ‫قابلیت‬‫ر‬
2‫تا‬4‫ثانیه‬
(‫انسد‬‫سرعت‬‫باالترین‬‫اد‬
‫به‬‫نسبت‬‫عروق‬
‫دیگر‬‫تکنیکهای‬)
‫ابعاد‬ ‫ای‬‫ر‬‫دا‬
‫وزن‬ ‫و‬‫کوچک‬
5/5‫کیلوگرم‬
‫نقل‬ ‫و‬‫حمل‬ ‫جهت‬
‫آسان‬.
‫هیچگ‬‫بنحویکه‬‫هوشمند‬ ‫کامال‬‫عملکرد‬‫ونه‬
‫دس‬‫روی‬‫کاربر‬ ‫ای‬‫ر‬‫ب‬ ‫وات‬‫تنطیم‬ ‫قابلیت‬‫تگاه‬
‫ندارد‬ ‫وجود‬
‫و‬‫ی‬‫گیر‬‫اندازه‬
‫یابی‬‫ز‬‫ار‬
‫بافت‬‫امپدانس‬
20000‫در‬‫بار‬
‫ثانیه‬
‫تا‬ ‫عروق‬ ‫انسداد‬
‫قطر‬7‫متر‬ ‫میلی‬
(‫تاییدیه‬ ‫ای‬‫ر‬‫دا‬
FDA‫آمریکا‬)
‫قابلیتهای‬‫و‬ ‫مشخصات‬
‫کمپانی‬ ‫عروق‬‫انسداد‬ ‫سیستم‬Covidien
‫مدل‬Valleylab LS10

124. Medtronic
TissueFect™ Reads tissue: 434,000 times per
second1
Software Upgradeable Ethernet connection (has WiFi
capabilities that are not yet
enabled)
Bipolar Cable Compensation Reads cable length and width
for consistent electrosurgical
output
Touch Screen Single, simplified touch screen
New ES Settings Soft coag
Dimensions • Weight (kg): 10.1
• Width (cm): 35.8
• Height (cm): 17.0
• Depth (cm): 46.2
Performance • Lower max jaw temperature3
• Faster sealing times (1-4
seconds vs. 3-6 seconds with
ForceTriad™)4
• Automatic power settings
require minimal setup and
mimize need for futher
handling during surgery
• Simple, intuitive controls and
information displays5
NEW ForceTriad
FT10

125. Medtronic

126. Medtronic
Thank You For Attention
Email: M.khojasteh@vartanik.ir
Tel: 051-38468026
Mobile: 09355524251