Dr. Prashant Sharma discusses the various types of surgical energy used in operations. He describes 6 main types: 1) Monopolar radiofrequency energy, the most common type which uses a dispersive electrode; 2) Bipolar radiofrequency energy which focuses energy between instrument tips; 3) Ultrasonic energy which uses vibration; 4) Plasma energy carried by argon gas; 5) Laser energy which can precisely control depth; and 6) Microwave and radiofrequency ablation which directly apply energy to induce tissue necrosis. Understanding surgical energy principles is important to minimize complications from electrosurgical injuries.
Different type of Energy Sources used in Surgery are described In this presentation...
like Radio frequency Electro-surgery
Ultrasound Energy
Laser
Argon beam Coagulation
This presentation will help u know with the history,present and coming up trends in laparoscopy .Also it is an acquaintance presentation regarding laparoscopy.
Basics of laproscopic surgery..
by dr navdeep s kamboj presented at sgrdumsar amritsar.
topics covered--
1 basics of laparoscopy
2 lap cholecystectomy
3 lap appendixcectomy
pneumoperitonem
merits and demerits of laproscopy
ligasure
endoscopy,
laparoscopic instruments
Different type of Energy Sources used in Surgery are described In this presentation...
like Radio frequency Electro-surgery
Ultrasound Energy
Laser
Argon beam Coagulation
This presentation will help u know with the history,present and coming up trends in laparoscopy .Also it is an acquaintance presentation regarding laparoscopy.
Basics of laproscopic surgery..
by dr navdeep s kamboj presented at sgrdumsar amritsar.
topics covered--
1 basics of laparoscopy
2 lap cholecystectomy
3 lap appendixcectomy
pneumoperitonem
merits and demerits of laproscopy
ligasure
endoscopy,
laparoscopic instruments
energy devices are d most important part of an operation theator and surgery. in this presentation i have briefly described various energy devices used in general surgery and laparoscopy.
This PPT is mainly on the Basic Principles of Minimal Invasive Surgery. The Final Yr. MBBS - Students shouls know the principles of Lap. surgery before going to their internship.
energy devices are d most important part of an operation theator and surgery. in this presentation i have briefly described various energy devices used in general surgery and laparoscopy.
This PPT is mainly on the Basic Principles of Minimal Invasive Surgery. The Final Yr. MBBS - Students shouls know the principles of Lap. surgery before going to their internship.
Haemostasis is very important in laparoscopic surgery. Vessel sealing with energy devises play a major role in keeping the surgical field clear. Energy devices are also used for tissue sealing and transection. Despite never types of energy devises electro-surgery is still very popular in gynaecological laparoscopy. Desiccation, dissection, and coagulation are the main effects of electro-surgery that are used for various purposes. Higher thermal injury with monopolar devices lead to the invention of bipolar devices with less tissue damage. Ligasure, pk gyrus, ENSEAL are some of the more advanced bipolar devices. Ultrasonic devices have the capability of coagulation and cutting tissues. During the process it can produce significant thermal injury. Thunderbeat combines bipolar and ultrasonic energy for coagulation and cutting respectively for more precise effects. Laser devices emit a beam of photons with a high degree of spatial and temporal coherence with tissue effects depending on the time of exposure and power density. CO2, Argon, Nd: YAG, KTP-532 are different laser types with different properties. Plasma is the fourth state of matter following solid, liquid and gas. Argon neutral plasma (System 7550TM ABC, Cardioblate) can produce energy in 3 forms including light, heat and kinetic energy. Laser and plasma energy are gaining more popularity for endometriosis surgery due to its localised effects and better preservation of ovarian follicles.
PRINCIPLES OF Electrosurgery
Electrosurgery is the application of a high- frequency electric current to biological tissue to cut, coagulate, desiccate, or fulgurate tissue.
PRINCIPLE
• Understanding the principles of electricity is a strong foundation for best practices in electro surgical patient care.
• Electrosurgical equipment and accessories facilitate the passage of high frequency oscillating electric currents through tissue between two electrodes to fulgurate desiccate or cut tissue.
MONOPOLAR
Active electrode at surgical site.
Return electrode at another site.
Current flows through the body.
Tissue effect takes place at a single active electrode and is dispersed (circuit completed) by a patient return electrode.
BIPOLAR
Active and return electrodes within the instrument.
Current flows confined to tissue between electrodes.
Current flows are limited and contained in the vicinity of the two electrodes.
As current passes through the tissue from one electrode to the other the tissue is desiccated and the resistance increases, as resistance increases current flow decreases.
laparoscopy and minimal invasive surgery is modern gyn surgical tool tool it is wise to know some basics about electro- cauterization … and how to avoid its dangers.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Surgical Energy
1. - DR. PRASHANT SHARMA
SURGICAL ENERGY
DR. PRASHANT SHARMA
2. INTRODUCTION
Surgical energy is an essential part of every operation; yet, the basic principles and application
remain poorly understood among surgeons of all ages and experiences.
Electrosurgical injuries account for over 5% of all laparoscopic complications and can result in
severe disability or death as well as a source litigation.
Public awareness of surgical energy complications significantly increased following the 2010
death of Pennsylvania Congressman John Murtha likely secondary to an electrosurgical injury.
To combat the widespread lack of in-depth knowledge, the Society of American Gastrointestinal
and Endoscopic Surgeons developed the Fundamental Use of Surgical Energy (FUSE) curricula
and certification.
• The FUSE curriculum has proven robust especially when accompanied by an interactive
component and is being rapidly accepted and applied internationally.
3. TYPES OF ENERGY IN THE OPERATING ROOM
1. MONOPOLAR RADIOFREQUENCY ENERGY
The most common device in today’s operating room is based upon the monopolar
device originally popularized by Dr. William Bovie and Dr. Harvey Cushing in the
1920s.
The “Bovie,” as it is commonly called in North American surgical suites, is a highly
versatile device that is used in open surgery, laparoscopy, and endoscopy and
permeates through all surgical specialties.
When activated, the electrosurgical unit (ESU) converts 60 Hz alternating current
from an electrical outlet to approximately 500,000 Hz of radiofrequency energy.
This travels from the tip of the instrument, through the tissue, and into the patient and
returns to the ESU via a dispersive electrode or “grounding pad”.
4.
5. Varying the duration of energy discharged (i.e., selecting “cut,” “coag,” or “blend” mode) from
the generator as well as the proximity of the tip to the tissue (e.g., current density) creates
three different clinic effects:
1. Vaporization (Cutting),
2. Desiccation (Coagulation),
3. Fulguration (Spraying).
VAPORIZATION (CUTTING) MODE
To cut or vaporize tissue, a low voltage/high current mode is selected (i.e., cut mode).
This is combined with a surgical technique that creates high current density (treating a small
amount of tissue near the thin tip of the instrument) during activation.
This focuses energy on a small area of tissue resulting in rapid heating of the cells to the
boiling point. Linear movement of the instrument cuts tissue with less than 200 μm of lateral
thermal injury.
6. DESSICATION (COAGULATION) MODE
To achieve more coagulative effect yet still move through tissue, a high voltage/low current
mode is typically selected (coag mode) and the current density reduced by increasing the area
of tissue contact with the instrument.
This raises cell temperatures more slowly to 60° to 95°C which results in protein coagulation
or “desiccation,” as opposed to vaporization.
A “blended” mode is a combination of the cut and coag waveforms which seeks to maximize
energy effectiveness by creating a safer, low voltage mode that can both cut and coagulate
tissue.
Desiccation of tissue with the coag mode is an effective way to increase coagulation during
dissection but should not be used for vessel sealing.
Vessel sealing is better accomplished in cut mode while grasping and occluding the vessel
with forceps. The apparent paradox (“cut” mode is more effective than “coag” mode for vessel
sealing) is due to the fact that the continuous cut waveform more evenly heats tissues for a
homogenous vessel seal as it cannot vaporize the cells due to the low current density created
by the relatively large amount of tissue held between the tips of the tissue forceps.
7. FULGURATION (SPRAYING) MODE
Superficial coagulation or “fulguration” is achieved most commonly in a high voltage/low current
flow mode (coag mode) while holding the instrument close but not contacting the tissue. Energy
can then arc to the superficial tissues creating temperatures in excess of 200°C.
The low current density rapidly heats and cools cells creating black eschar as a result of the
breakdown of elements, especially carbon, into their atomic components.
Thermal penetration is typically 5 mm or less.
The versatility and effectiveness of monopolar radiofrequency energy in surgery continues to
increase as alternative modes and techniques of operation emerge.
Energy devices and generators that continuously monitor tissue effect during activation are
already available.
When combined, these new devices and techniques all bring the surgeon closer to the ultimate
goal of energy application: the ability to utilize the smallest amount of energy possible to create
the desired tissue effect.
8.
9. 2. BIPOLAR RADIOFREQUENCY ENERGY
Bipolar devices contain both limbs of the electrical circuit in a single device so as to focus
radiofrequency energy solely on the tissue between the instrument’s tips.
This reduces the required voltage from 1,400 to 9,000 V during monopolar energy use to
approximately 100 to 200 V.
Basic bipolar devices are designed for coagulation of tissue alone; however, newer devices
are available that have added a cutting blade to transect tissue.
These “advanced” bipolar devices often include tissue feedback mechanisms and audible
tones to notify the surgeon when the tissue is ready for transection.
This slightly increase operative time and smoke production when compared to other
devices but has the benefit of consistently sealing vessels up to 7 mm in diameter.
Bipolar energy is highly useful while operating on delicate tissues and in the tissues with
high neural density. e.g. during Thyroidectomy
10.
11. 3. ULTRASONIC ENERGY
Ultrasonic devices convert low-voltage radiofrequency energy into high frequency
(approximately 44,000 Hz) mechanical vibrations via piezoelectric crystals in the device
handle.
These rapid vibrations generate friction that heats tissue, denatures proteins (coagulates), and
creates tissue separation (cuts) at temperatures below boiling.
A transient mist is formed due to the cavitation effect of the vibration but minimal charring
(tissue temperatures do not exceed 100°C) and lateral thermal spread is seen on low settings.
This facilitates dissection and decreases operative time in contrast to monopolar and bipolar
instruments.
Ultrasonic devices can effectively seal vascular structures up to 3 mm in size although newer
devices can reportedly seal larger vessels by increasing dwell time.
A Harmonic Scalpel is the device that works on this principle and is widely used in surgical
practice now.
12.
13. 4. PLASMA ENERGY
Radiofrequency energy can be applied in short, 40 μs bursts to create plasma energy along
the edge of a device.
Plasma energy can also be carried onto the tissue itself by an inert gas, most commonly,
argon.
When combined with short bursts of high-voltage radiofrequency energy, plasma energy can
provide tissue cutting and coagulation functions with minimal thermal spread.
Argon plasma coagulators are thus designed for the superficial coagulation of diffusely
bleeding tissue (e.g., cut liver or spleen).
They are highly effective in a bleeding or debris-filled field and produce less smoke than
monopolar or bipolar devices with a constant thermal spread of 2 to 3 mm.
However, intravascular embolism of insoluble argon gas has resulted in cardiac arrest and
death; thus, avoidance of direct tissue contact and minimal gas flow volume is recommended.
14.
15. 5. LASER ENERGY
Lasers generate heat by focusing a concentrated beam of light on tissue.
They can be used for both cutting and coagulating tissue and were quite common in the 1980s
and early 1990s.
Due to their high cost, need for specialized training and general increase in operating times
lasers have been relegated to use in limited, specific scenarios. e.g. Hemorrhoid laser surgery.
Precise control of the depth of penetration promotes their continued use in dental, eye,
cosmetic, anorectal and gynecologic fertility procedures.
16. 6. MICROWAVE AND RADIOFREQUENCY ENERGY ABLATION
• Microwave or radiofrequency energy can be applied directly to tissue to induce necrosis in
either an open or percutaneous fashion.
• The goal of this directed use is typically tumor necrosis or arrhythmia ablation.
Radiofrequency ablation devices take many different forms (bipolar, monopolar, internally
cooled, etc.) and function via the principles of monopolar and bipolar energy discussed above.
• Significantly larger amounts of radiofrequency energy are used and extra care should be taken
to decrease the risk of electrosurgical complication.
Microwave ablation devices function within a different part of the electromagnetic spectrum
(frequencies between 915 MHz and 9.2 GHz) and create tissue effect via dielectric heating.
• The microwave energy causes rapid alternation of the positive and negative poles within cells.
The charged ions (especially water) rotate every time the positive and negative poles switch
polarity (approximately 109 times per second) and this creates rapid and uniform heating of
cells within the microwave field.
No dispersive electrode is needed as no circuit is created—heating is a direct result of the
microwave energy on the cells.
17. • Both radiofrequency energy and microwave ablation are susceptible to nearby perfusion which
can reduce complete ablation rates.
• Radiofrequency energy will follow the path of least resistance as it travels to the dispersive
electrode so nearby vasculature, bile ducts, lymphatics, and so forth can serve as an “electric
sink.”
• Microwave ablation can also be affected by nearby perfusion acting as a “thermal sink.” As no
circuit is created, no electrons are stolen but the constant flow of liquid removes heat just as an
automobile radiator cools an engine.
A distinct benefit of microwave ablation is the ability to achieve high tissue temperatures (150°C)
in contrast to the 60° to 100°C limit that guides energy flow during radiofrequency energy ablation.
This can result in shorter ablation times (typically 4 to 10 minutes).
Both modalities can be successfully used to achieve complete tumor ablation and use is often
guided by availability and experience.
All surgeons should be aware of the different mechanisms of action in order to minimize the risk of
electrosurgical complication.
Due to each device’s complexity and relative rarity of use, utilization with imaging guidance and
manufacturer assistance is recommended.
18. NEW TECHNIQUES AND INSTRUMENTS
VESSEL SEALING TECHNOLOGY
• Combination of pressure and energy to create a seal.
• Feedback controlled output so reliable seal in minimal time
• Seals vessels up to 7 mm with a single activation.
• Seal strength comparable to sutures/clips, can withstand >3 times
normal pressure
• Lateral thermal spread :
LIGASURE: 0 - 4.5 mm
ENSEAL TRIO: 1 mm
19. LIGASURE
Combination of Press Advance Bipolar
Device.
Pressure and Energy.
Feedback Controlled System.
Rachet Grips Vessels tightly.
Measures resistance in tissue
and sends to generator.
Continues till vessel is sealed.
20. • Seal time: 2-4 seconds
• Seals vessel upto 7 mm
• Tolerates 3 times SBP
• Max. Temperature 60-90⁰C
• Thermal Spread 4.5 mm
21. ENSEAL
Only System Control energy deposition.
Nanopolar thermostat in jaws.
Adjusts energy according to tissue
impedance.
Less heat required:
Tissue Volume reduced by
compression.
22. THUNDERBEAT™
World’s 1st and only integrated
energy system.
Integration of ultrasonic and bipolar
technology.
Rapid cutting of tissues with ultrasonic
energy and sealing of vessel with
bipolar energy.
Minimal thermal spread.
Improved visibility due to reduced
mist.
Allows upto7 mm sealing.
Precise dissection.
23.
24.
25. THE EIGHT REPRODUCIBLE PATTERNS OF ELECTROSURGICAL
INJURY
Energy-based device have become ubiquitous in the contemporary operative room.
Increasing use has resulted in more complications that adhere to eight common patterns of
injury:
1. Fires,
2. Antenna Coupling,
3. Insulation Failure,
4. Residual Heat,
5. Direct Application Interaction With Electronic Devices,
6. Direct Coupling, And
7. Capacitive Coupling
26. Fires
Operating room fires and explosions are fortunately rare events (550 to 650 per year) but can
result in significant injury or death.
In order for a fire to occur, three elements must be present:
1. Heat or an ignition source (i.e., surgical energy, patient or fluid warmer),
2. Fuel (alcohol-based prep, surgical drapes, etc.), and
3. Oxygen.
• The majority of surgical fires occur in the airway (21%) or around the upper chest, head, and
neck (44%) likely due to increased oxygen content.
• Utilization of closed breathing circuits (i.e., endotracheal tube) as opposed to nasal cannula or
mask oxygenation as well as maintaining oxygen content at ≤30% will minimize risk.
Should a fire or explosion happen the following steps should be immediately undertaken:
1. Stop the flow of all airway gases and disconnect the patient from the breathing circuit including
removing the endotracheal tube during an airway fire;
2. Remove any burning or burned materials;
3. Extinguish the fire from the burning materials by dousing it with saline, smothering it or utilizing
a carbon dioxide fire extinguisher.
27. If the fire is not contained by these steps then practitioners should follow the acronym:
RACE:
Rescue; attempt to rescue the patient or staff.
Alert; activate the fire alarm and alert nearby staff.
Confine; isolate the fire by closing doors, shutting of medical gas and electrical power.
Evacuate; evacuate the incident room and entire surgical suite if necessary.
Preventative Strategies:
Education of the surgeon and operating room staff on the three elements needed for fire
creation taking special note of oxygen-rich environments such as the airway or under surgical
drapes.
Do not place surgical drapes until alcohol-based preps are completely dry without pooling
Enter the airway with cold surgical instruments with the patient on the minimal amount of
oxygen enrichment necessary to maintain appropriate saturations (goal oxygen content
<30%).
Maintain the fiber optic light in stand-by or “off” mode any time that it is not connected to the
laparoscopic telescope.
28. Antenna Coupling
Electrosurgical injury due to antenna coupling has only recently been elucidated but is thought
to be a major source of thermal injury.
Radiofrequency energy, most commonly from the wire/cable of monopolar devices, can be
transmitted into the air (through intact insulation) and into nearby conductors (cables,
instruments, or monitoring electrodes).
Antenna coupling is one of the most ubiquitous sources of electrosurgical complications during
monopolar energy use as any wire/cable that lay within close proximity of the “Bovie” cord (or
return electrode cord) will pick up stray energy and can burn the patient.
Close proximity and parallel alignment of instruments/wires/cables has also been shown to
increase tissue temperatures nearly 60°C.
The forced parallel alignment and close proximity of Single Incision Laparoscopic Surgery
(SILS) also increases antenna coupling and the resultant thermal injuries may be an explanation
for the increased postoperative hernias and incisional pain.
The simple maneuver of separating the cords has been consistently shown in benchtop and in
vivo trials to reduce the incidence of antenna coupling.
29. Preventative Strategies:
1. Separate the active electrode and dispersive electrode cords from other nearby wires/cords.
2. Minimize voltage by decreasing power, using lower power modes (cut or blend), or switching
to lower power bipolar/ultrasonic devices.
3. Avoid use of monopolar energy during single incision laparoscopic surgery.
30. Insulation Failure
Electrosurgical injury via insulation failure is thought to be one of the most common causes
of inadvertent thermal injury during laparoscopy.
It may also be the most easily managed. Insulation defects can be found in up to 39% of
monopolar instruments, typically near the instrument tip as the insulation begins to thin and
taper.
Interestingly, these defects (and resultant injuries) are more common during robotic surgery.
Unfortunately, just 10% of insulation defects are visible to the naked eye; thus, some authors
suggest routine use of porosity detectors during sterile processing of laparoscopic
instruments.
Preventative Strategies:
1. Careful inspection of the instrument prior to use for obvious breaks in insulation.
2. Maximize visualization of entire instrument during activation to identify aberrant energy
arcs. For laparoscopy and endoscopy this often requires pulling the telescope back into
the port or out of the patient to see the “big picture.”
3. Routine porosity detection of reusable laparoscopic instruments including any devices that
may be connected to energy (e.g., L-hook, spatula, graspers, and/or scissors).
31.
32. Residual Heat
• Residual heat is defined as the increased instrument temperature after energy activation is
completed.
• The rate of increase and maximal instrument temperature is unique to each device and
causes injury when the tip touches tissue prior to complete heat dissipation.
• This is most commonly seen with ultrasonic devices which reach higher maximum
temperature (>200°C) and remain hot longer than bipolar or monopolar devices.
Clinical Example:
• During laparoscopic hemi-colectomy, the ultrasonic device is used to transect the
transverse mesocolon and then immediately used to grasp/retract small bowel resulting in a
full thickness injury and delayed perforation.
Preventative Strategies:
Delay use of ultrasonic devices for grasping or dissecting until at least 5 seconds have
passed after activation (2 seconds for advanced bipolar and monopolar devices).
33.
34. Direct Application
Electrosurgical injury via direct application is a result of unintentional activation of any type of
instrument while contacting tissue.
Clinical Examples:
1. While leaning against the patient, the surgeon unintentionally activates the monopolar
device resulting in a burn to the patient at a site remote from the surgery.
2. The monopolar “bovie” is activated directly on the staple line of an intestinal anastomosis
and focuses on a single staple resulting in enormous current density and melting of the
staple with staple-line breakdown
Preventative Strategies:
1. Routine use of protective “holsters” or “sleeves” when devices are not in use.
2. Activate devices with the tips fully visualized and containing only the tissue intended to
coagulate and/or cut.
3. Understand the activation cycle of each device.
35.
36. Interaction With Electronic Devices
Radiofrequency energy transmitted through the air interferes with nearby monitoring
devices such as ECG leads, neuro-monitoring devices, and even implanted cardiac
devices.
The transfer of energy into monitoring cables hampers waveform interpretation and can
cause direct thermal injury via antenna coupling.
In addition, the transferred energy can interfere with implanted cardiac device sensing and
cause malfunction.
Preventative Strategies:
1. Utilize low power settings or low energy devices (bipolar, ultrasonic) when operating on
patients with implanted cardiac devices.
2. Avoid use of energy devices near or parallel to the implantable device current vector.
37.
38. Direct Coupling
Direct coupling is intentionally created when the surgeon touches the monopolar device to a
forceps or other conductor while grasping tissue to coagulate.
Complications arise when energy is unintentionally transferred to a nonelectrically active
conductor.
Clinical Examples:
1. A monopolar instrument with an extension is activated in the pelvis while unintentionally
touching a forceps that is retracting the ureter during a low anterior resection resulting in
delayed ureteral injury.
2. A monopolar, laparoscopic L-hook is activated near the tip of the metal suction–irrigation
resulting in energy transfer to the suction tip and into unintended tissue.
Preventative Strategies:
1. Avoid contact with other conductive instruments prior to activation.
2. Maintain complete visualization of the monopolar electrode in contact with the tissue.
39.
40. Capacitive Coupling
Capacitance is stored electric charge when two conductors are separated by an insulator.
This stored energy can be transferred, through intact insulation, into nearby conductors
(such as the bowel) resulting in thermal injury. Capacitive coupling occurs almost
exclusively with monopolar energy use due to its high voltage.
Clinical Examples:
1. The laparoscopic monopolar L-hook is activated and capacitive energy is discharged
directly into bowel contacting the insulated shaft of the instrument resulting in a delayed
bowel injury.
2. Prior to the development of video cameras for laparoscopy, surgeons looking directly
through the eyepiece of the laparoendoscope would suffer burns to their eyes due to
capacitive coupling.
Preventative Strategies:
1. Utilize lowest power setting to achieve effect or low energy devices (bipolar, ultrasonic).
2. Avoid the use of combined metal/plastic laparoscopic trocars.
3. Maintain complete visualization of instruments during energy activation.
41.
42. CONCLUSION
The best energy device for a particular patient and surgery is dependent on a multitude of factors.
The characteristics of each energy device should be considered in addition to other factors such
as device availability and user experience which are not universally quantifiable.
Monopolar energy remains the most common and versatile instrument in the surgeon’s energy
armamentarium.
It is everyone’s responsibility in the operating room to understand how electro-surgery works and
to take steps to ensure the patient’s safety.
As our understanding of surgical energy device function increases so should the safety of our
operating rooms.
Choosing the right tool for the job requires an evidence-based approach as well as lifelong
learning.