ELECTROSURGERY IN LAPAROSCOPY

79-year-old woman underwent lap Cholecystectomy Discharged in 2 days, Collapsed and died, 4 days later. Autopsy, Extensive soiling of the peritoneal cavity with fecal material Source of leakage : 2 perforations in the transverse colon. Pathologist remarks Histological appearance of the perforated tissue suggested "coagulative necrosis consistent with thermal injury."

Basics of Electrocautery Monopolar and Bipolar cautery Electrosurgical Accidents Prevention APC, CUSA Harmonic Scalpel Ligasure

Modern Electrosurgery Thermocoagulation Heating of wire placed between 2 electrodes Modern Electrosurgery No heating of the electrode Passes high frequency current through the tissues Electrical resistance of the tissues - heat

Electrosurgery 1928 – Bovie’s machine Principle Electricity in the frequency range 50,000 – 2 million Hz Heat – Protein denaturation, Coagulative necrosis Hemostasis

Electrosurgery Electrosurgical Generator : Active Electrode : Conducts current from generator to patient Return Electrode : Accepts current from Active electrode and returns to generator 10 1 ESG

Monopolar Bipolar

Advantages of Bipolar Concentrated current at specific point Less tissue damage (other areas) No return electrode No capacitance coupling Power needed only 10% of monopolar Output 50 – 150 ohms Monopolar 30 – 500 ohms

Bipolar Vs Monopolar 20 Temp Rise 10 4 2 Distance mm

UNIQUE ENVIRONMENT IN LAP Limited access, Limited field of vision, Presence of insufflating gas Low heating capacity, Instruments may not cool rapidly Combustion - N2O Use of Cannulas – Capacitance coupling

Limited access, Limited field of vision

UNIQUE ENVIRONMENT IN LAP Limited access, Limited field of vision Presence of insufflating gas Low heating capacity, Instruments may not cool rapidly Combustion - N2O

TYPES OF CURRENT CUTTING & COAGULATION :

In Laparoscopy CUTTING : Tip of the hook High density current 10 1 CUTTING : Tip of the hook High density current COAGULATION : Blunt side of hook Low density current FULGURATION : Blunt side , kept at a short distance Low density, shallow coagulation

ELECTROSURGICAL ACCIDENTS I have not seen one !!!!! They are very rare !!!!! Seen only in text books !!!!! Is it true ??

We do not recognise them Bile duct injuries Bile leaks Intestinal Injuries Anastamotic leaks Post operative leaks Skin burns Ground pad burns

ELECTROSURGICAL ACCIDENTS Most common reason Insulation Failure

INSULATION FAILURE ZONES Voyles CR, Tucker RD Am J Surg 1992

Zone I – within the view Repeated trauma (insertion, withdrawal) Repeated heating, poor handling Sterilisation Manufacturing defect Z 1 Z 2 Z 4 Z 3

INSULATION FAILURE

Zone 3 Arcing from instrument to trocar Abdominal wall jerking Interference in video monitors Z 1 Z 2 Z 4 Z 3

Zone 4 Injury to surgeon Z 1 Z 2 Z 4 Z 3

Direct Coupling Instrument touching other areas Instrument in contact with other instrument

CAPACITANCE COUPLING 2 conductors separated by insulator + air gap Energy gets stored Accumulated energy discharges through point of contact between cannula and instrument

CAPACITANCE COUPLING

CAPACITANCE COUPLING

Prevention

Knowledge about electro surgical hazards Proper understanding of the basic principles and physics behind cautery

Avoid Activation of cautery : When tissues & instrument are not in contact Outside the visual field Near metallic objects (clip, staple, scope, metal instruments) Metal Cannulas with plastic sleeves Use of un-insulated instrument

ARGON PLASMA COAGULATION

APC Argon gas + Monopolar Cautery Ionised argon gas Bridges tissue and electrode Denaturation of surface proteins, eschar formation Low temperature Precise fulguration

Disadvantages Solid organ parenchyma division in minimally invasive surgery Limited cutting ability Lack of tactile feed back Risk of gas embolism

HARMONIC SCALPEL

vessels are coapted (tamponaded) and sealed by a protein coagulum. HARMONIC SCALPEL : Coaptive coagulation vessels are coapted (tamponaded) and sealed by a protein coagulum. 55,000 Hz Electrosurgery & LASER : Obliterative coagulation Formation of eschar that covers and seals the bleeding area.

Cutting and Coagulation Modes

ADVANTAGES Less lateral thermal damage Minimal smoke ? clearer visual field No electrical energy passed through the patient Less Lateral Tissue Damage

CUSA Ultrasonic waves – 23,000 Hz Cavitational fragmentation of parenchyma Aspirated from the field Solid organ surgery

CUSA

LIGASURE Collagen and elastin within the tissue melt and reform to create the seal zone. Initial resistance of tissue measured Appropriate energy settings choosen Energy : pulsed and adaptive (Continuous feedback) cycle stopped when response complete High current (4 amps), low voltage (<200 volts)

LIGASURE

LIGASURE

ADVANTAGES Reduced thermal spread No foreign body left behind Upto 7 mm vessels can be coagulated Burst pressure > 3 times systolic BP Only seconds to complete

1992, Minnesota case A 31-year-old patient claimed that her surgeon's negligence during surgery resulted in perforation of her colon $ 2.8 million compensation awarded with an additional $2 million for "pain, disability, disfigurement, embarrassment and emotional distress. "Woman awarded $2.8 million in medical malpractice case," Minneapolis Star Tribune (April 13, 1996).

1993, Florida Case 38-year-old nurse, underwent adhesiolysis for pelvic adhesions Malpractice suit was against the gynecologist. The Florida jury found the gynecologist liable $ 551,891—$51,891 for past medical expenses $ 300,000 for past pain and suffering $ 200,000 for future pain and suffering. $ 1,051,891 in total Two of the surgeon’s expert witnesses testified that bowel ischemia resulting from stray energy burns coincidental to the monopolar electrosurgery caused the damage Trudy Karl vs. Rufus S. Armstrong, M.D. Florida Jury Verdict Reporter. 1993;14:47-48.

1994, Washington case Laparoscopic removal of her gallbladder. The operating room record indicated that throughout the surgery, the video monitor registered "electrical interference" that "made continuing the procedure extremely difficult." High-grade stricture of common hepatic duct, repeated surgeries Expert witness testified that the injury was most likely the result of electrosurgical burns to the hepatic duct during the periods of "electrical interference." Verdict : “surgeon was negligent in causing the injury” and to award the victim $250,000. Golden TR. Laparoscopic cholecystectomy verdict. Trial News. April 1993:20.

Predictors of complications after formal training in lap surgery Short term laparoscopic training course 3 months and 12 months Complications Only course Additional 3 months 3.39 times 12 months 4.48 times Attended course alone, solo practice, variable assistants Attended course with a partner, group practice, same assistant WA, Cooper et al,Predictors of laparoscopic complications after formal training in laparoscopic surgery.JAMA. 1993 Dec 8;270(22):2689-92.

MONOPOLAR CAUTERY & BIPOLAR CAUTERY Can be safely used in laparoscopic surgeries HARMONIC SCALPEL Useful tool for advanced laparoscopic procedures LIGASURE New technology for bloodless laparoscopic surgeries

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