Electro surgery in Gynaecology

Dept. of OBGYN M.K.C.G.Medical College Berhampur, Orissa, India

History
Heat therapy known since antiquity Heat cures when everything fails Hipocrates. Albucasis (980BC) used hot iron to stop bleeding. Then followed use of electrical current on a metallic element.
This method just burns the tissues.

But modern electro surgery or Surgical Diathermy is a recent technology, which entails passage of high frequency electrical current through tissues.
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History
Earliest recorded use of this technology was by Arsenne d Arsonval in1893. However extensive use of electro surgery in brain surgery by Harvey Cushing & William T. Bovie and their publication in 1925 promoted Electrosurgery. They described three distinctive effects Desiccation Cutting Coagulation
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Electro cautery and Electro surgery

Electro cautery Electro surgery Direct current High Frequency through a high Alt. Current resistance through living metallic conductor tissue It is essentially Manipulation of application of heat electrons to and burning of produce heat tissue within the cells to destroy the tissue
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Basics of Electricity Two types of Current Direct Current (DC) Alternating Current (AC)
DC flows continuously in one direction AC flows in two directions, first increasing to a maximum in one direction & then increasing to a maximum in the opposite direction in a sinusoidal wave form.

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Electro surgery in Gynaecology - Prof.S.N.Panda

Basics of Electricity
Alt.Cur. has a positive & a negative peak.

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Electro surgery in Gynaecology - Prof.S.N.Panda

Alternating Current Alt.Current can be generated in Three types of wave form:1) Continuous / Uninterrupted / non-modulated wave form (CUT) : Produced by continuous delivery of energy

2) COAG- Interrupted / Modulated / Dampened / Varied wave form: when energy is delivered only 10% of the time

3) Blended wave forms: Produced by delivering energy at variable intervals, which can be controlled / varied thus producing both effects
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Alternating Current
1) Continuous / Uninterrupted / nonmodulated (CUT) wave form:- Produced by continuous delivery of energy

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Electro surgery in Gynaecology - Prof.S.N.Panda

Alternating Current
2) COAG- Interrupted / Modulated / Dampened / Varied wave form:-. when energy is delivered only 10% of the time

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Electro surgery in Gynaecology - Prof.S.N.Panda

Alternating Current
3) Blended wave forms:- Produced by delivering energy at variable intervals, which can be controlled / varied thus producing both effects

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The Machine (Generator)

It produces the required type of electricity in the patient circuit by induction from the supply line. It has been undergoing constant improvement.
1st. Generation- Tungsten contacts. 2nd.Generation- Valve Generators. 3rd. Generation- Transistor technology. 4th. Generation- Digital Electronics technology. Latest- Microprocessor controlled diathermy,
User programmable, auto functions, error detection, safety alarms & cut offs. Constant power delivery Under water application, soft & spray coagulation and bipolar cut possible.
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Effect of Electricity on Living Tissue

Electrolytic Effect Faradic Effect Thermal Effect

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Electrolytic Effect
Produced by DC/ AC of very low frequency (<5kHz). The +ve & -ve ions in the cell move to the ve & +ve poles. Electrolytic damage to the tissue.

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Faradic Effect
Produced by AC of >20 kHz Stimulation of nerve & muscle cells Undesirable Can be avoided by using current of >300kHz

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Thermal Effect
Produced with AC >300kHz Tissue gets heated leading to three possibilities, depending on Current density, Duration of application & Specific resistance of the tissue.

This is the effect for clinical use.

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Thermal Effect: - Possibilities

Electrosurgical Cutting with / without Coagulation Desiccation Coagulation / Fulguration

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Electrosurgical Cutting +/Coagulation

Very rapid heating of cells No time for evaporation Steam formation-PressureCells burst With continuos current only cutting With blended current - both cutting & coagulation.
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Electrosurgical Desiccation
Tissue is gradually heated Water is slowly driven out Cell plasma coagulates Cut blood vessels shrink Bleeding stops Can be done with MP Ball / Needle electrode or bipolar Coagulating Forceps.

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Electrosurgical Desiccation

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Bipolar Diathermy
Current flows locally through a small portion of tissue between two electrodes of the bipolar forceps

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Bipolar Diathermy
Advantages
Technique is precise & safe for the patient. Preferred in endoscopic surgery. Unintentional burns avoided. Causes less disturbance to other electronic equipments connected to the patient.

Disadvantages
Only small amount of tissues can be handled. Cutting possible only with microprocessor controlled machine.
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Monopolar Diathermy
High frequency current flows from the active electrode through the patients body to the patient plate. It produces heat in the tissues proportional to the electrical resistance of the tissues and the current density. Fatty tissues have a high resistance. Electrosurgical Cutting with / without Coagulation and Desiccation / Fulguration all are possible.

Patient plate is required.

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Patient Plate
It is the negative pole / passive electrode through which the current returns to the machine after passing through the patient. The current density at the patient plate is inversely proportional to the contact area. A 50% decrease in contact area near the patient plate will produce two fold increase in current intensity and a four fold increase of heat.
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Patient Plate
Hence the Patient plate should be as large as possible. It should be applied to a wide area of electrically more conductive tissues like muscles.

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Patient Plate
Current does not flow uniformly to the patient plate. Its density is higher at the corners and edges of the patient plate nearer to the the active electrode. Hence the patient plate should be placed such that the longer edge points to the active electrode.

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Patient Plate
It should make maximum and complete contact with the electrically conductive surface of the body to avoid burns. Metal plates not to be used. Large Silicon rubber plates should only be used. Simple patient plates are not so simple.

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Diathermy in GynaecologyGeneral Use

During surgery ( Open & Laparoscopic) for Cutting & Haemostasis.
Cutting is more precise. Haemostasis is better achieved.

Can be used in LSCS. No effect on the fetus. Take care while working near vital structures. Apply the point first , then switch on the current. Monopolar & or Bipolar can be used.

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Diathermy in GynaecologySpecific Use

Benign Cervical LesionsCIN (LEETZ / LEEP)Tubal SterilisationOvarian Drilling in PCODEndometriosisLaparoscopic MyolysisHysteroscopic surgery- TCRE, sub mucus Myoma, Septum Resection
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Electro surgery for Benign Cervical Lesions Coagulation / Desiccation / Cutting can be done as the case may be, using Monopolar diathermy in the following conditions.
Erosion & Chronic Cervicitis - Avoid endocervix Mild degree Cx. Tears Amputation

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Electro surgery for CIN

Known as Large Loop Excision of the Transformation Zone (LLETZ) or LEEP (Loop Electrosurgical Excisional Procedure). A wire loop electrode on the end of an insulated handle is powered by an electrosurgical unit. The current is designed to achieve a cutting and a coagulation effect simultaneously. Power should be sufficient to excise tissue without causing thermal artifact. The procedure can be performed under local analgesia. Treatment success reported varies from 91% to 98%.
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Electro surgery for Tubal Sterilisation Tubal sterilisation is usually done either by mini- laparotomy 0r laparoscopy with almost equal results. But laparoscopy requires more sophisticated and expensive equipment and greater skills. Laparoscopic sterilisation should usually be done by a single puncture and use of monopolar coagulation as described by Wheeless [Wheeless 1992].
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Female Sterilisation methods

Ten-Year Cumulative Probability of Pregnancy (per 1000 procedures)
40
Probability 35 per 30 1000 procedures 25

36.5
24.8 20.1 17.7 7.5
clip bipolar interval ring mono

20 15 10 5 0

18.5 7.5
PPTL overall
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Method
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Electro surgery for PCOD

For PCOD, Laparoscopic Ovarian Drilling (LOD) by Diathermy is cost effective than Laser vaporization. It is done by passage of 40 W current for 4 seconds in 4 places on each ovary with a monopolar needle. Advantages of ovarian drilling Sensitizes the ovary to F.S.H. Less monitoring than Gonadotrophin therapy. Unifollicular growth, No risk of OHSS and multiple pregnancy. Low rate of abortion. One treatment may result in many ovulatory cycles. Ovulation rate 70 80% in failed C.C. cases, Pregnancy rate 60%

To reduce periovarian adhesions liberal peritoneal lavage should be done. Early second look laparoscopy and adhesiolysis may be required.
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Electro surgery in Endometriosis

During surgery for endometriosis, small and multiple lesions on the peritoneum are better dealt with electrocoaglation. Care should be taken while working near vital structures. Though both monopolar and bipolar may be used, bipolar is safer and preferable.

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Electro surgery for Myoma

Myolysis - involves delivering electric current via needles (Monopolar) to a fibroid at the time of laparoscopy. It offers a better alternative to myomectomy with minimal blood loss to deal with myomas particularly multiple ones.

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Hysteroscopic Electro surgery Endometrial ablation - Tran Cervical Resection of Endometrium (TCRE), with wire loop or roller ball is a simple office procedure.
It can be the first line of surgical treatment in Menorrhagia (DUB) and may avoid hysterectomy.

Other hysteroscopic electrosurgical procedures are Electrovaporisation of sub mucus Myoma. Septum Resection
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Conclusion
Modern diathermy is a versatile & useful surgical tool. Advancements in the technology has opened up many new vistas in treatment. Its proper & judicious use can not only benefit the patients but also will make the surgery more efficient, comfortable and simple. However utmost care has to be taken during its use so as to avoid catastrophes.
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ELECTROSURGERY

At the service of women

A THANK YOU
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