Electrosurgical Unit (ESU)

By: Yassir Ali

Introduction
Electrosurgery has been described as high-frequency electrical current passed through tissue to create a desired clinical effect 1. Electro surgery means the application of radio frequency (RF) current at frequencies between 300 kHz and 5 MHz to achieve a desired surgical result; typically the fusion of tissues or surgical cutting in which the tissue structure is disrupted. 2. The effect is achieved by heat dissipated in the tissues from the RF current by resistive, or joule, heating. 3. This method has the ability to cut and coagulate tissues at the same time ; and, as a consequence, has made substantial contributions to several branches of clinical medicine since its introduction in the late 1920s

Electrocautery
Electrocautery is the intentional burning of tissue with a hot surgical instrument, such as a wire-looped hyfrecator, that is heated by using direct current. During electrocautery, the patient is not part of any electrical circuit and there is no ability to moderate or control the thermal effects on tissue with any precision

Electrosurgery vs. Electrocautery

Electrocautery is the intentional burning of tissue with a hot surgical instrument, such as a wire-looped hyfrecator, that is heated by using direct current. During Electrocautery, the patient is not part of any electrical circuit and there is no ability to moderate or control the thermal effects on tissue with any precision

Introduction

Electrosurgery units and accessories facilitate the passage of high frequency, oscillating electric currents through tissue between two electrodes to fulgurate, desiccate or cut tissue. Electro surgery is done by generating and delivering high frequency alternating current between an active electrode, through living tissue, and to a return electrode.

Electro surgery units

Introduction

Electrosurgical devices

The RF frequencies used for electrosurgery fall between 350 kHz and 4-5 MHz, depending on manufacturer and intended use.

Applications of different current frequencies

Introduction

Electro surgery units

The physiological stimulus (electrical current ) The effect of the stimulus, also known as the faradic effect, is expressed by the formula

Why high frequency ?

50- 60 cycles per second creates nerve stimulation and electrocution. High radio frequency eliminates nerve and muscle stimulation and electrocution.

Current density
Current density refers to the intensity of the current as it passes through the tissue. When current is concentrated, heat is produced and the amount of heat produced determines the tissue response. The smaller the application area, the greater the current density at the application site.

Figures shows the effect of surface area

Resistive, or joule, heating

DArsonval discovered that electricity can cause body temperature to rise. The temperature change was noted to be a function of the current density. The transformation of electrical energy into heat occurs in accordance with Joules Law and can be expressed by the following formula:-

During RF electrosurgery, the electromagnetic energy is converted in the cells first to kinetic energy then to thermal energy When an oscillating current is applied to tissue, the rapid movement of electrons through the cytoplasm of cells causes the intracellular temperature to rise.

Joule's thermodynamic law

Electrosurgical instruments are based on the principle of converting electrical energy into heat. The basic principle is laid down in Joule's law of thermodynamics in which the relationship of the amount of heat to the electric current (I), the ohmic resistance (R) and the duration (t) is expressed as . The amount of heat generated is determined by:1. The square of the current 2. The setting of the power splitter 3. The ohmic resistance of the physical tissue as a total of the resistance of the area in contact with the active electrode (e.g. blood, muscle or fatty tissue)

Resistive, or joule, heating

The amount of thermal energy delivered and the time rate of delivery will dictate the observed tissue effects. 1. Below 45C, thermal damage to tissue is reversible. 2. As tissue temperatures exceed 45C, the proteins in the tissue become denatured, losing their structural integrity. 3. Above 90C, the liquid in the tissue evaporates, resulting in desiccation if the tissue is heated slowly or vaporization if the heat is delivered rapidly. 4. Once the tissue temperatures reach 200C, the remaining solid components of the tissue are reduced to carbon.

Impact of temperature on cells and tissue

Regulating the thermal effect

Regulating the thermal effect through:
1. 2. 3. 4. 5. 6. Current and output power Modulation level Shape of electrode Condition of active electrode Cutting speed and duration of action Tissue properties

Electrosurgical device parts

1. The Generator 2. Active electrode 3. Passive electrode (The return electrode)

Electrosurgical device parts

Active Electrodes

Dual Dispersive Electrodes

Bipolar Forceps

Types of electrosurgical instruments

Electrosurgical technology offers essentially two types of devices for energy delivery: 1. Monopolar 2. Bipolar
The monopolar instrument, the Bovie being the most common example, delivers current through an active electrode, which then travels through the patient and back to the generator through a conductive adhesive grounding pad applied to the patient before beginning the procedure.

Types of electrosurgical instruments

Monopolar refers to the circumstance with only a single electrode viewed as near the surgical site. A monopolar electrode may have no circuit return element provision. Typically > 1 MHz, capacitive coupling provides return. A monopolar electrode may have a circuit return element remote from the surgical site. Note that the return electrode is large in surface area to provide low current density away from the surgical site. A bipolar tool has a return electrode near the surgical site, to eliminate current away from the surgical area. A fundamental concept is that the only part of the patient involved in the circuit is the tissue interposed between the two electrodes Figure from Cutaneous Electrosurgery, J.E. Sebben (1989). Note: These are simplifications, significant safety improvements made in intervening years.

Monopolar VS. Bipolar

Tissue Effects of Electrosurgery

1. Cutting
Vaporization of tissue is best achieved with a continuous, low-voltage waveform, using a unipolar instrument with a narrow, pointed or blade-shaped electrode held near to but not in contact with the tissue.

2. Desiccation and White Coagulation

3. Fulguration
Is superficially coagulated by repeated high-voltage electrosurgical arcs that continue to elevate the temperature by resistive heating to beyond 100, reaching levels of 200C and more

Active electrode & Passive electrode

Electrosurgical Generators

Electrosurgical Generators
The ESU converts the low-frequency AC from a wall outlet 5060 Hz into higher-voltage RF output, typically from 300 to 500 kHz Such ESUs are also capable of producing a number of different waveforms that allow the surgeon to change the impact of the energy on the targeted tissue All modern ESUs have ports for the two electrodes in the circuit, and controls that allow the surgeon to set the power output for each of the waveforms.

The RF Generator
1. Spark gap/ Vacuum tube 2. Parallel connection of a bank (Bipolar ) 3. Bipolar transistor with MOSFETs

Spark gap device

Simplified circuit showing the spark gap generator

Vacuum Tube Oscillators

The switching is done here using vacuum tube Designs utilized vacuum tube oscillator circuits that were typically:Tuned-Plate Tuned-Grid Oscillators V1and V2, oscillates on opposite half cycles of the mains power The output of vacuum tube electrosurgical units is available as either partially rectified or fully rectified

Solid-state generators

Solid-state generators
The fundamental frequency, most often 500 kHz, is generated by a master oscillator circuit, typically an a stable multivibrator The primary oscillator acts as the clock or timing reference for the rest of the generator The unmodified master oscillator signal is amplified and used for cutting. An interrupted waveform is formed by gating the continuous oscillator output through an external timing circuit Constant power output is obtained by measuring the output voltage and current and adjusting the drive signal to compensate for changes in the equivalent load impedance The sampling rate for this adjustment is on the order of hundreds of hertz

Advantages: -

Solid-state RF generators made possible much more sophisticated waveforms and safety devices in a smaller overall package Solid-state generators utilize wave synthesis networks that drive a power amplifier output stage. Quite complex waveforms may be employed for cutting and coagulation.

Solid-state generators

Passive electrode

Different types of state of the art neutral electrode

Today there are four different types of state of the art neutral electrodes. They fall into the following groups:1. Disposable neutral electrodes 2. Reusable neutral electrode 3. Single neutral electrode 4. Split neutral electrode(Dual Plate Return Electrodes)

Passive electrode Safety

1. selection of as large a neutral electrode as possible. 2. Application ensuring full contact of the neutral electrode's active surface. 3. Keep neutral electrode surface free of soiling and residue. 4. Avoid bony protrusions, scar tissue and implants. 5. Ensure non-slip application (rubber bands). 6. Shave strong hair growth without using alcohol. 7. Position neutral electrode as close to the operating area as possible.

Continuity Monitor
Verifies that a return electrode is connected to electrosurgical unit

Cannot detect if return electrode is disconnected from or in poor contact with the patient

Electrosurgery Safety Features

Return Electrode Contact Quality Monitor

Assures that good contact exists between the dispersive electrode and patient

Dual Plate Return Electrodes

The patient return electrode is divided approximately into halves and a small current (5mAor less) at high frequency but below the surgical frequency (typically in the neighborhood of 100 kHz) is applied between the electrode halves, the connection being through the skin The impedance between them is monitored, and if it exceeds maximum or minimum limits an alarm sounds and the generator is deactivated

Active electrode

Some types of active electrodes

Active electrode tips

Coated Active Electrode

Benefits of PTFE Coating 1. Easily cleaned 2. Non-stick properties 3. Resistant to high temperatures 4. Bendable

Footswitch

Factors affecting the performance

1. 2. 3. 4. Tissue Impedance Surface of the exposed area The conductivity of the tissue Current density

Variables Impacting the Tissue Effects of Electrosurgery

1. 2. 3. 4. 5. 6.

Power Density Electrode Surface Area Electrosurgical Generator Power Output Tissue Impedance or Resistance Waveform Time on or Near Tissue

combination of factors decide the techniques

power settings. electrode dwell time. volume of treated tissue. proximity of tissue to active. electrode. current density.

Color code output Jacks

Yellow for cut Blue for coagulate Red for active electrodes Black for inactive electrode

Relative voltage and thermal spread at different generator settings

Crest factor
The generator ability to coagulate without cutting CF = peak volts rms volts

Typical Output Characteristics of ESUs

Typical Output Characteristics of ESUs

Relationship of instrument settings to voltage and current interruption

ESU Hazards
Risks to patients, operators and third parties can arise from a number of possible causes. Relevant literature, accessible statistics and experience gained by companies show these to be: 1. Technical deficiency 2. Unwanted high frequency burning 3. Incorrect operation 4. Defective accessories 5. Ignition of flammable fluids and gases 6. Risks from improper combination with other equipment

ESU Hazards
1. 2. 3. 4. 5. 6. Electric shock and undesired burns. Undesired neuromuscular stimulation Less frequent Interference with pacemakers or other devices Electrochemical effects from direct currents Implant heating Gas explosions

Laparoscopic Electrosurgery

Unintended coupling of active electrode with a non-insulated instrument.

Precaution and safety constrains

The skin temperature should not rise more than 6C above the normal surface temperature of 2933C. The current density at any point under the dispersive electrode has to be significantly below the recognized burn threshold of 100 mA/cm2 for 10 seconds any electrosurgical generator that provides for an output power of greater than 50 W shall have at least one patient circuit safety monitor

Precaution
The patient circuit monitoring device should be operated from an isolated power source having a maximum voltage of 12 Vrms output isolation transformer present in most modern ESUs The correct placement of an active electrode will also prevent the patient and surgeon from being burned To minimize the probability of unwanted neuromuscular stimulation, most ESUs incorporate in their output circuit a high-pass filter that suppresses dc and low-frequency current components.

OR Safety Precautions
Avoid oxygen enriched environments The active electrode should be placed in a clean, dry, well-insulated safety when not in use Cords not be wrapped around metal instruments Cords should not be bundled together

Proper use and safety

The following are some suggestions to avoid injury to the patient and to the surgeon and operating team :1. The simplest means of avoiding injury is to always use the lowest possible generator setting that will achieve the desired surgical effect and to never exceed the power settings recommended by the manufacturer 2. Frequent cleaning of the electrode tip is recommended

Reference
Nader N Massarweh, MD, Ned Cosgriff, MD, Douglas P Slakey, MD, MPH,FACS,Electrosurgery: History, Principles, and Current and Future Uses Malcolm G. Munro, Fundamentals of Electrosurgery Principles of. Electrosurgery.