complication_laparoscopic_electrosurgery

Complications of Laparoscopic Electrosurgery : 

Complications of Laparoscopic Electrosurgery Dr. Mohammed Abdalla Domiat general hospital

Why we are rushing towards minimally invasive surgery? : 

Why we are rushing towards minimally invasive surgery? less disruptive to tissues patients generally recover faster with less pain fewer wound problems less scarring

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In operative laparoscopies we often use electricity either to cut, desiccate or coagulate; but major catastrophes may arise if non targeted tissue is injured.

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So before we use this tool it is wise to know some basics about electrocautery… and how to avoid its dangers.

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Electricity almost always searches for a conductor to reach the ground

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Alternating current 60 HZ House hold current Faradic effect resulting in cardiac arrest Below 100 KHz Neuromuscular stimulation Above 350 KHz Radio frequency and used in ESU thermal effect

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convert standard electrical frequencies from the wall outlet, which are 50 to 60 Hz, to much higher frequencies, 500,000 to 3,000,000 Hz Electrosurgical unit

Monopolar Electrosurgery : 

Monopolar Electrosurgery dispersive pad

Bipolar Electrosurgery : 

Current path is confined to tissue grasped between forceps blades. Bipolar Electrosurgery

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current R heat Increased resistance TISSUE IMPEDANCE Eschar buildup Any current with this frequency meet resistance produce heat

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current Patient Return Electrodes

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current Patient Return Electrodes

Patient Return Electrodes : 

Patient Return Electrodes It should be applied to a wide area of electrically more conductive tissues like muscles. Don't use metal plates Use Large Silicon rubber plates

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  The large surface area of the dispersive pad results in low current density at the attachment site If the dispersive pad becomes loose with only partial skin attachment, or of surface area the current density increases at the attachment site

Patient Return Electrodes : 

The patient plate should be placed such that the longer edge points to the active electrode.   Patient Return Electrodes

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Constant waveform, is able to vaporize or cut tissue. Interrupted waveform will produce less heat. and coagulation. Blend 1 cut > coagul. Blend 3 coagul. > cut

Current adaptation to its effect : 

Current adaptation to its effect

Three factors lead to stray energy burns : 

Three factors lead to stray energy burns direct coupling capacitive coupling insulation failure

direct coupling : 

direct coupling

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The higher the peak voltage, the greater the chance for capacitive discharge A capacitor creates an electrostatic field between the two conductors capacitive coupling

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The low voltage “cut” mode exhibits less capacitive coupling than coag does. Surgeons must recognize that open circuit activation (electrode not touching tissue) dramatically increases voltage and the possibility of capacitive coupling. It is desirable to use as low wattage as possible and to limit noncontact activation of the generator.

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insulation failure Insulation defects can range from normal wear and tear, to stress placed on the electrode from high voltages. The smaller the defect, the higher the current density transferred

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How to avoid

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When possible, place the long edge of the electrode closest to the surgical site and on the same side of the body as the incision if it is a sided procedure. Choose a well vascularized muscle mass. Avoid areas of vascular insufficiency, irregular body contours, bony prominences.

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Remove excessive hair. Check equipment before each use Patient skin is not in contact with metal or, if so, these areas are Insulated.

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Solutions are not stored on top of power unit. Power cord, dispersive pad cord, and cautery pencil cord are carefully placed to avoid possibility of being tripped. It is recommended that Cords not be wrapped around metal instruments Cords not be bundled together

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Foot pedal is dry. Power unit is operated at lowest possible setting. Flammable substances are used with care when power unit is in operation.

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Inspect insulation carefully Use a low voltage waveform (cut( Use brief intermittent activation vs. prolonged activation

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Do not activate in open circuit . Do not activate in close proximity or direct contact with another instrument .

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Use bipolar electrosurgery when appropriate Select an all metal cannula system as the safest choice. Do not use hybrid cannula systems that mix metal with plastic. 

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• Activate the electrode when touching tissue. • Clean the active tip routinely during surgery to prevent eschar buildup, which can cause tissue to stick and set up resistance to current flow. • Visually inspect instruments throughout each procedure.

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Utilize available technology, such as a tissue response generator to reduce capacitive coupling or an active electrode monitoring system.

Perioperative Management of Patients with Cardiac Rhythm Management Devices : 

Perioperative Management of Patients with Cardiac Rhythm Management Devices Assure that the electrosurgical receiving plate is positioned so that the current pathway does not pass through or near the cardiac rhythm management devices (CRMD system) avoid proximity of the cautery's electrical field to the pulse generator or leads. use short, intermittent, and irregular bursts at the lowest feasible energy levels. reconsider the use of a bipolar electrocautery system or ultrasonic (harmonic) scalpel in place of a monopolar electrocautery system, if possible.

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Terminate current at the end of vapor phase Apply current in pulsatile fashion Alternate between desiccation and incision Bipolar surgery

TAKE HOME point : 

TAKE HOME point Injuries related to stray currents (insulation failure, capacitive coupling, and direct coupling) are most effectively eliminated with actively monitored electrodes,  metal cannulas, and an informed surgeon.

Thank you : 

Thank you