1. ELECTROSURGERY IN LAPAROSCOPY

2. 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."

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

4. 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

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

6. 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

7. Monopolar
Bipolar

8. 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

9. Bipolar Vs Monopolar 20
Temp
Rise 10 4 2
Distance mm

10. 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

11. Limited access, Limited field of vision

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

13. TYPES OF CURRENT
CUTTING & COAGULATION :

14. In Laparoscopy CUTTING : Tip of the hook High density current10 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

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

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

17. ELECTROSURGICAL ACCIDENTS
Most common reason
Insulation Failure

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

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

20. INSULATION FAILURE

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

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

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

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

26. CAPACITANCE COUPLING

27. CAPACITANCE COUPLING

28. Prevention

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

30. 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

31. ARGON PLASMA COAGULATION

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

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

34. HARMONIC SCALPEL

35. 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.

38. Cutting and Coagulation Modes

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

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

41. CUSA

43. 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)

44. LIGASURE

45. LIGASURE

46. 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

47. 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).

48. 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.

49. 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.

50. 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 times
12 months 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 Dec 8;270(22):

51. 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

52. thank you