1. Electro-Surgery in
laparoscopic surgery
RCMC.BASIC LAPAROSCOPIC COURS
Dr.Medhat M. Ibrahim
Consultant pediatric surgeryand
Minimal access surgery.

2. Introduction
Many energy sources are avilable to:
Cut,
Coagulate,
evaporate tissue ,
The objective of this study is;
understanding the energy source

3. Basic electro-surgical circuit – (Monopolar)
Surgeon
Source - Gen
Patient
Active cable/Path
Return cable/path
Power supply
Patient Return Electrode

4. High current density at the narrowing of
an electrical conductor creates heat
220 Volt 50 Hz

5. Tissue on plate is part of the circuit
High current density
= heat development in tissue
Active Electrode
Low current density / No heat development in tissue
Return Electrode
220volt/50Hz

6. Why not 50 Hertz
 Alternating current at frequencies from
1 to 100,000 Hertz will interfere with the
neuro-muscular system.
 Above 100,000 Hertz these stimuli occur
too quickly to affect the neuro-muscular
system.

7. 350 KHz to 3.3 MHz
Electrosurgery
Household
Purposes
Neuromuscular
Stimulation ceases
AM Radio FM Radio
TV
50 Hz 550 Khz
1550 Khz 54 – 880 MHz
100 Khz
Below 100 Khz – Electrical shock Above 100 Khz - No electrical shock

8. What it does?
Vapourises
& De-Hydrates
across almost all tissue types

9. Basic electro-surgical circuit - Monopolar
Source - Gen
Patient
Active cable/Path
Return cable/path
Surgeon
Power supply
Patient Return Electrode

10. Vaporization & De-Hydration
 Cut/Vaporization:
High current concentration at active electrode causes
intense heat in tissue (above 100c)
 Coagulation (Dessication)
Intermittent supply of current to a larger electrode
causes less intense heat into tissue (below 100c),
allows heat dispersion

11. Coagulation
Cut
Energy
Intense Energy
Dehydration through heating
Coagulated cell
Cell expands through
increase in pressure
Exploded cell

12. Wave forms
pure cut blend cut desiccation fulguration
Pure cut uses the lowest level of voltage

13. Monopolar Electrosurgery
Cut
Pure Blend
Coagulation
Fulguration Dessication

14. Pure cut Blend Fulguration/non contact coag

15. Dessication 1

16. Dessication 2

17. Dessication 3

18. Spray coagulation
or fulguration
Blade electrode
Principle: Bleeding vessel
Current follows
Path of least
resistance

19. Limiting power settings by limiting contact
Blade electrode Micro Needle electrode
Choice of electrode & technique determines tissue effect
Forceps - tips

20. The electrosurgical effect is influenced by:
1. Contact Time
2. Power Settings of Generator
3. Type of electrode used (Current Density)
4. Whether Cut or Coag activated
5. Tissue Impedance
6. Distance from Active to Return

21. Bipolar electrosurgery in egg white/glass

22. Bipolar Forceps coagulation
Saline
Correct
Correct
Incorrect
Incorrect

23. Some Issues
Usually, a very safe device to use,
however, these machines are often seen as
the most hazardous device used in an OR!
WHY?

24.  The patient return electrode
 General rules for safe practice
 Minimally Invasive Surgery issues

25. Pad site burns are prevented by assuring
optimal conditions at the pad-patient
interface.
High current concentration/density
Low current concentration/density

26. Pad site burns are caused by adverse
conditions at the pad-patient interface
which result in increased current density.
 Current density increases when
– current removal area is too small
– heat is applied for too long
– power setting is too high
High current
concentration/density

27. Plate Burns !!!

28.  A burn under the patient plate is
ALWAYS
negligence

29. Monitoring Current
RF Current
RF Current

30. Basic rules
1. Position plate as close as possible to
surgical site
2. Check contact of plate throughout
procedure

31. Avoid the following patient plate locations
 Scar tissue
 Metal implants
 Pacemakers
 Bony structures
 Monitoring electrodes
 Areas of moisture concentration

33. Glove burn (“Bovie-bite”)

34. Result glove burn
!!
Whoops???

35. Causes of glove burn
 Activation of fulgurate or spray output
 High power settings
 Surgeons technique
Open circuit activation
Removal of forceps whilst activating
Carbonisation causes higher leakage current due to increased resistance
 Quality of gloves
Recommendation: Use Cut or Dessicate

36. Other Complications
• Bowel gas ignition
• Staple line/clip conductivity
• Current Density Complications
• Prep fluid

37. Electrosurgery Safety
Considerations for
Minimally Invasive Procedures

38. Direct Coupling
Laparoscope
View
Active
Electrode
Telescope
with Camera
Metal
Instrument
Bowel

39. Insulation Failure
Abdominal Wall
Electrode Insulation Failure
Electrode Tip
Laparoscopic View
Metal Trocar
Cannula
Bowel

40. Insulation Failure

41. Thermal injury caused by Insulation Failure of electro-surgical instrument
during Laparoscopic Cholecystectomy

42. Intended Current
Flow
Induced
Current
Metal Coil
Conductor
Air
(Insulator
Metal Coil
Conductor
Capacitor

43. Capacitance Increases with Use of
– Longer instruments
– Higher voltages
– Narrower diameter
cannulas
L

44. Instrument/Metal Cannula Configuration
Creating a Capacitor
Abdominal Wall
Conductor
(Electrode Tip)
Conductor (Metal Cannula)
Insulator (Electrode Insulation)
Laparoscopic View

45. Instrument/Plastic Cannula
Configuration
Can capacitive coupling occur?
Abdominal Wall
Conductor
(Electrode Tip)
Insulator (Plastic Cannula)
Insulator (Electrode Insulation)
Laparoscopic View

46. Instrument/Hybrid Cannula Configuration
Capacitively Coupled Fault Condition
Capacitively Coupled
Energy to Metal Cannula
Electrode Tip
Plastic Collar
Bowel

47. Energy dispertion
Energy Dispertion

48. Hybrid Trocar/Cannula System
You make one yourself.

49. Conclusion
Electro-Surgical devices can be a potential hazard
in an Operating Room.
However, they can also be very safe,
its always the driver in control!