Safe use of electrosurgery in gynaecology -- Dr Muhamed Al Bellehy MD Consultant Obstetrics and gynecology

1. Safe use of electrosurgery in
gynaecology
Dr Muhamed Al Bellehy MD
Consultant Obstetrics and gynecology
Dr Muhamed Al Bellehy MD

2.  the two types of electric current:
o direct current (DC), which moves in one direction
(unidirectional),
o AC, which periodically reverses direction
(bidirectional).
Electrosurgery electrocautery
the application of high‐frequency
alternating current (AC) in surgery to
achieve various thermal tissue effects
including cutting, desiccation and
coagulation.
the passive transfer of
heat to the tissue with no
current passing through
it.
 uses AC with high frequency
o AC to avoid electrolysis
o high frequency to avoid the
Faradic effect of nerve and
muscle stimulation.
 uses DC
Faradic effect ceases at frequencies >
100 kHz.
Because frequencies commonly used in
are >500 kHz, which are similar to
radiofrequency (RF), the term RF
electrosurgery is used.
Dr Muhamed Al Bellehy MD 2

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5. • Surgical diathermy = electrosurgery
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8. Power (Battery) produces difference in
voltage  current
Resistance will decrease the current
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9. Battery produces difference in voltage
 current
Resistance
Change
electricity
into
another
form like
heat or
light
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10. Increasing the voltage will result in a
higher current
Increasing the resistance will result in a
lower current
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12. Power is expressed as Whatt = amount
of energy delivered in time unit
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13. Electrosurgical unit = voltage
Electrical
switch
Tissue effect= increase
temperature
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14. Power
increase temperature
Depends on
Resistance
Duration
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15. Maximum amount of
power
In Voltage
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16. amount of power for certain effect
Depends on
Resistance
Type of
electrode
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17. Voltage vs power controlled generators
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18. • Electro surgery uses alternating current not direct current
• direct current will result in electrolysis
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19. Electro surgery uses higher frequency to avoid tissue stimulation
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21. Current flows 100% of
time + > 200 V
Tissue Vaporization Cutting
Current flows 6% of
time
Tissue Cools in between
 form a coagulum
Coagulation +
Some Cutting when > 200 V
Dr Muhamed Al Bellehy MD 21

22. Cutting
Coagulation +
Some Cutting when > 200 V
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23. Coagulation +
Some Cutting when > 200 V
BLEND mode
Activate Current and higher Voltage in a certain way to obtain effect mixed
of cutting and coagulation
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27. Monopolar
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29. Bipolar
• Only used for tissues
that could be grasped
• Effect between two
the blades only
• So- relatively safe
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30. Gap between two
blades
No Gap between two
blades
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31. Jaw of bipolar forceps
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32. Dispersive blade
Active blade
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33. Contact area at
Dispersive blade 10000
times > active electrode
Current density at
Dispersive blade 10000
times < active electrode
Temp at Active
electrode 10000 times >
Dispersive blade
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37. Increasing the Contact
area of the active
electrode decreases
current density  more
coagulation
decreasing the Contact
area of the active
electrode increases
current density  more
cutting
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39. AKA electrosection
• Active electrode is held just
lightly against the tissue
• Using the cutting or blend
modes
• When using the blend mode
cutting + hemostasis of small
BVs
Excessive power  sparking and tissue drag
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40. AKA Spray
AKA non contact coagulation
• Use spark or fulguration mode
• Active electrode is held a small
distance from the tissue
• Spark of, electricity will pass to
the tissues  minimal tissue
heating + large superficial
coagulum
Dr Muhamed Al Bellehy MD 40

41. • Use spark or fulguration mode
• Active electrode is held a small
distance from the tissue
• Spark of, electricity will pass to
the tissues  minimal tissue
heating + large superficial
coagulum
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44. • Coagulation mode *bi – mono
polar*
• Active electrode is held in
direct contact with the tissue
• This result in less heat gradualy
delivered and Spark of,
electricity will pass to the
tissues  deep coagulum
Dr Muhamed Al Bellehy MD 44

45. • Use spark or fulguration mode
• Active electrode is held a small
distance from the tissue
• Spark of, electricity will pass to
the tissues  minimal tissue
heating + large superficial
coagulum
Dr Muhamed Al Bellehy MD 45

46. • Best with bi polar*
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48. Cutting mode can coagulate in
power controlled generators
Coagulation mode can cut when >
200 Volte
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53. General considerations for
• The tip of the electrode
• The body
• The dispersive blade
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55. Surgical Smoke
• May obscure visualization
• May have health hazards –
contain toxic gases
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56. Smoke evacuator may be used
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57. Bowel perforation and injury
to perianal region will result in
leakage of methane and
hydrogen  ?? fire
Alcohol disinfectants
not allowed to dry
?? fire
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58. Hand held electrodes should
be kept in non conductive
place to avoid danger of
accidental activation
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59. Activating the active electrode
when the not in contact with
patient’s body electrical
glove burns
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60. Activating the active electrode when the
surgeon is in contact with active electrode and
the patient  electrical pathway through the
surgeon’s hand  electrical glove burns
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61. Prolonged Activation of the active electrode 
increased residual heat  tissue injury
Short Activation of the active electrode should
be practiced
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62. Prolonged Activation
of the active
electrode 
increased heat 
carbonization + tissue
sticks to the electrode
As the active
electrode keeps
contact with the
tissue 
carbonization of
the sticking tissue
continue further
increase resistance
 decrease
clinical effect
 staff
wrongly
increase the
power
settings
the tip of the electrode should be kept clean !
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65. Grounded Generators
1. The ground is part of the circuit
between the dispersive blade and
the generator
2. Current pass through the
dispersive blade to the ground
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67. Alternative Grounded objects
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68. Alternative
Grounded
objects
Operating Table and
accessories
IV stand
Older ECG electrodes
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69. When the contact area
with the grounded object
is small and the
resistance is less than
that at the dispersive
blade
high current density at
the contact area 
alternate site burn
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70. Isolated
generators
The ground is not part of the circuit
between the dispersive blade and
the generator
The Current pass through the body and the
current returning through the dispersive
blade can be measured – and must be
almost equal
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71. Isolated
generators
When the difference between Current the
passes through the body and the current
returning through the dispersive blade– is
too large  system is deactivated
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72. Isolated
generators
When the difference between Current the
passes through the body and the current
returning through the dispersive blade– is
too small  system is not deactivated
When the difference– is too small  not
necessarily indicates a leak
Thus there is a
small possibility
of alternate site
burn
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73. Allow for a small leak Thus there is a small possibility
of alternate site burn
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74. A visual check before the procedure, to
confirm that the patient is not contact with
a conducting object
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75. Electricity may pass through a conducting
implantable  burns
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76. The dispersive blade should not be placed
near or over a conducting implantable
Piercings and jewelry near the surgical site
should be removed
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77. Short bursts for 6 seconds
Use bipolar
Avoid monopolar over
surrounding tissues
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80. Contact area at
Dispersive blade 10000
times > active electrode
Current density at
Dispersive blade 10000
times < active electrode
Temp at Active
electrode 10000 times >
Dispersive blade
Dr Muhamed Al Bellehy MD 80

81. When Contact area at
Dispersive blade is
reduced
Current density at
Dispersive blade is
increased
When Contact area at
Dispersive blade is
severely reduced 
circuit blade burn
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82. When choosing the site of dispersive blade consider
• Surgical site
• Contact with the table
• Accessories
• implants
Close to surgical site
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83. When choosing the
site of dispersive blade
consider
• Choose a well
vascularized
muscular area
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85. Poor placement of the
Dispersive blade 
contact area is reduced
Decrease tissue effect
Staff increase power
output
Increase chance of
burns
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86. Use the largest suitable
blade
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88. Return electrode
monitoring (REM)
Uses a small amount of
current to measure the
conduction between the
two blades of the split
blade
If high resistance  small
contract area or poor
tissue conduction
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89. Return electrode
monitoring (REM)
Uses a small amount of
current to measure the
conduction between the
two blades of the split
blade
If high resistance  small
contract area or poor
tissue conduction
THEN DEACTIVE THE
SYSTEM
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90. THEN DEACTIVE THE
SYSTEM
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91. 2 BLADES SHOULD BE AT SIMIALR
DISTANCE FROM THE SURGICAL SITE
X
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93. As the current flows in the cords 
electromagnetic field
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94. When the cords are bundled
stronger electromagnetic field
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95. When the cords are wrapped around an instrument 
electromagnetic field will charge it with electric current
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97. When the cords are wrapped around an instrument 
electromagnetic field will charge it with electric current
 patient injury if in contact
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98. Do not use near any electronic devices or connections
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104. Jaw of bipolar forceps
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106. View during laparoscopy is limited to a conical area in
front of the endoscope
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107. Contact of the instruments with tissues outside filed of
vision  injury
• Bleeding
• Perforation
• Leakage of body fluids
• Ignition of bowel gases
X
• Do not activate the current when instrument is not
visualized or near any organ or other instruments
• Avoid contact of the tip shortly after activation
• Avoid prolonged activation of current to reduce
residual instrument heat
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112. high voltage causes spark  Direct coupling with out contact

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113. To avoid this
• As low voltage as possible
• Cutting > coagulation
• Activate the current only when in direct conatct with the
tissues
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120. When monopolar current is
used at high voltage 
creates high
electromagnetic field 
charge nearby instruments
with current
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121. This does not occur with
bipolar instruments, as the
electromagnetic field has
opposing directions
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122. Metal trocars disperses the
charge through the skin
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123. Hybrid trocar systems
induces capacitive coupling
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129. Bipolar electro surgery is
preferred
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