1. Electrosurgery & Gyn Surgery: Get the Point Across
M. Jonathon Solnik, MD, FACOG FACS
Director, Minimally Invasive Gynecologic Surgery
Dept OB/Gyn, Cedars-Sinai Medical Center
Assistant Clinical Professor
Dept OB/Gyn, David Geffen School of Medicine at UCLA

2. What’s the difference ?
Electrocautery: use of a direct electrical current to heat up a metal conductor with a high impedance to flow so that the metal becomes physically hot.
Electrosurgery: manipulation of electrons through living tissue using an alternating current with enough concentration to create heat within the tissue and cause destruction.

3. Electrosurgical Generator (ESU)
Machine that creates an alternating current with enough current density (concentration) to heat and destroy tissue
Sinusoidal waveform that is bidirectional
The waveform can be
altered to create
different surgical
effects
Radio Frequency (RF)
The frequency (>100 kHz) is above that which stimulates muscle or nerve

4. Look Familiar ???

5. How is tissue destroyed ?
Electric energy is converted to heat (no net change)
Each waveform passes through both positive and negative ‘peaks’ – the intracellular polarity is interrupted, creating cellular heat.
44-50 C
50-80 C C C
>200 C
Visible
None
Blanching
Shrinkage
Steam
Carbonized
Delayed
Necrosis
Sloughing
Ulceration
Crater
MOA
Metabolism
Denature
Desiccate
Vaporize
Combust
Odell RC. Surgical Energy Sources 2002

6. Waveforms CUT COAG Continuous Simple Undamped High current Low Voltage
Rapid tissue heating  vaporization
Non-contact
Less thermal spread
COAG
Intermittent
Cooling effect
Damped
Lower current
Higher voltage
Less cellular heat
Contact or non-contact
Risk of thermal injury
Blend 1 – lower voltage, shorter time-outs
Blend 2 – higher voltage, longer time-outs

7. CUT Waveform BLEND Interrupted CUT current with increasing Voltage
Blend of surgical effects
Reduced current/time
1 – more cut / 3 – more coag
Improved hemostasis
Requires more time to CUT
Blend 1 – lower voltage, shorter time-outs
Blend 2 – higher voltage, longer time-outs

8. COAGULATION Fulguration (COAG) Desiccation (CUT>COAG) Non-contact
Coagulates by ‘spraying’
Heat lost to air
Superficial eschar – carbonization (HOT)
Oozing surfaces
Minimal depth of necrosis (0.5-2mm)
Stop when bleeding stops
Desiccation (CUT>COAG)
Contact
All heat transmitted to tissue
Deep & wide tissue necrosis
Discrete bleeder
Gaps in hemostasis - can spark thru coagulated tissue – bipolar better
Electrode can stick to tissue as it heats
With desiccation, be patient – it takes time for the larger electrode and smaller power density to create its effect. If you increase the energy, you may have more sticking and more sparking resulting in fulguration (which stops the deep tissue process).

9. Electrode-Surface Interface
Temperature at which the current heats the tissue is directly related to the size of the electrode and how it contacts the tissue
Temperature ∆ = (i x 2 / r x 4) X R x t
Small electrode (r) – HOT
Dispersive electrode (grounding pad) – minimal tissue change
High tissue tension (R)– affects tissue resistance

10. Video – CUT vs. COAG

11. Monopolar vs. Bipolar Current

12. Resectoscope Loop Ultra-fine Vapor pocket Electrons do the work
Vapotrodes
aggregation of electrons
Monopolar
nonconductive, uncharged
Bipolar
doesn’t matter

13. Thermal Injuries in MIS
Active electrodes can be long
True visual field is limited -- flying blind !!!
Delayed Presentation
73% of injuries after L/S chole went unrecognized1
3-10 days or longer2
Evaluate pain, urinary retention, nausea or fever
SLS Survey 1995
13% of surgeons had at least 1 malpractice case
Tucker RD, et al. AORN J 1995
Reich H. Surg Laparosc Endosc 1992

14. The probability of incurring a thermal injury during operative hysteroscopy increases with monopolar energy.
True
False

15. Hazards of Electrosurgery
Direct injury with active electrode
These are high energy burns
Alternate Ground Burns
Division of current  ECG leads
Isolated ground circuitry
Patient Return Electrodes (dispersive)
Previously accounted for 70% of injuries
The large size
Low conductivity
Interpolated REM
Placement
ZAP !!

16. Capacitative Coupling
This phenomenon cannot be eliminated
Abdominal wall often serves as a return to ground
Plastic cannulas may not provide more protection than metal cannulas
Tucker RD, et al. AORN J 1995
Reich H. Surg Laparosc Endosc 1992

17. Which setting should be used when resecting an intracavitary myoma?
Bipolar resectoscope using Blend 2
Monopolar resectoscope using pure CUT
Monopolar resectoscope using pure COAG
Bipolar resectoscope using pure COAG

18. Insulation Failure Instantaneous burns with HIGH-power density
Often occur in Zone 2 (outside of surgical field)
Can occur repeatedly causing serious injury

19. Prevention, prevention, prevention
Know and inspect your instruments
Adjust power according to desired effect
Use a low voltage waveform (CUT)
Use short & controlled bursts
Practice skill sets in the lab