15Coagulation and Cutting devices in Laparoscopic Urology
16Monopolar energy is the most preferred in 74%. BJU 2005Overall score 41%.Monopolar energy is the most preferred in 74%.Monopolar energy is used by >85% for laparoscopic procedures.Emergency Care Research Institute (ECRI): the rapid increase of laparoscopy has created simultaneous increase in injuries from ESI.
18Monopolar cautery. Monopolar Electrosurgical Coagulates vessels upto 2 mmCurrent leaks, insulation breaks.Capacitative coupling.Contact with other conducting instrumentsThermal spread to vital structuresCharring of tissuesmokeThe mechanism for monopolar energy-based surgical injuries is either from direct leakage of current flowing throughdefects in active-electrode insulation, or by capacitive leakage of current originating from the shaft of the active electrode. Capacitive monopolar current leakage is particularly worrisome with laparoscopic procedures, as the injury will most commonly occur outside the surgeon’s field of vision and might go unrecognized. In a study in 1994, thePhysician Insurers Association of America found that during three-quarters of cases in which laparoscopic injury occurred, the injury was not recognized before the end of the procedure. The risk of surgical complications is inextricably linked to the surgeon’s fundamental knowledge of instrumentation, surgical technique, applicable biophysics, and relevant anatomy. It is incumbent upon surgeons of all specialities to understand the devices in dailyUse.
22The Harmonic Scalpel Mechanical energy Electrical energy Piezo-electric crystals in the hand-piece become excited.Disk transfers electrical energy into mechanical energy.Mechanical energyElectrical energy
23The Harmonic Scalpel Blade vibrates at 55,000/sec 50o C 100o C Blade extenderSilicon nodesProtein coagulationPiezo-electric crystals in the hand-piece become excited.Disk transfers electrical energy into mechanical energy.Blade vibrates at 55,000/sec50o C100o CProteins Disorganise to form a coagulum
25Harmonic Vs Electrocautery Simultaneously cuts and coagulates soft tissue and vessels AND seals lymphaticsYESNOLower temperatures on tissue (50oC-100o C vs 150oC to 400oCMinimal lateral spread and tissue damageNo charring, dessication and tissue stickingReduces smoke, mist or vapor for improved visibility
26The Harmonic Scalpel: Technique Tissue tensionBlade sharpnessTimePower levelGrip force
31Conventional bipolar vs. modern technique feedback-controlled bipolar vessel sealinghigh current, low voltagepulsating energy”cooling intervals”simultaneous compression appliedinstruments measure the current between jaws during coagulationminimal thermal spreadsealing effectdenaturation of collagen and elastin fibersno thrombus formation
33Bipolar: LigasurePermanently fuses vessels upto and including 7 mm in diameterUnique combination of pressure and energy to create vessel fusion.Feedback-controlled system automatically discontinues energy when seal cycle is complete.
35Mean burst pressure(mmHg) by device EBVS (Ligasure)128601442UCS(Harmonic)226205175Plastic clip737854767Ti clip757593628Harold KL et al., Surg Endosc 2003
36FDA approval ultrasonic energy for vessels up to 3 mm EBVS (elctrothermal bipolar vessel sealer) for vessels up to 7 mm
37Extent of thermal injury by device EBSV (Ligasure)2-3 mmUltrasonic scalpel (Harmonic)0-1 mmLandman J et al., J Urol, 2003
38Bipolar: Gyrus Plasmakinetic system Plasmacision leverages the electrically conductive properties of tissue fluid to form a tightly defined low-temperature plasma field.In Plasmacision cut phase, the plasma corona precisely divides tissue.In bipolar coag phase the Plasma knife tip delivers controlled RF to elevate tissue temeperature, dessicating and sealing blod vessels.
39Bipolar: EnsealUtilises a nanotechnology feedback system wherein the temperature is adjusted by feedback from the nanoparticles in the device.Minimises lateral thermal spread.
45Ligasure instruments create a wider seal All four instruments efficacious and safe in sealing and cutting blood vesselsAll instruments created good seals with supraphysiologic bursting pressuresEnseal highest bursting pressure, however even lowest bursting pressures were in supraphysiologic rangeLigasure instruments create a wider sealHeating higher with Harmonic ACEHarmonic ACEENSEALGyrus PK
46Its the Magician not the Wand who creates the Magic!!