Electrosurgery: principles and practice to reduce risk and maximize efficacy.

Science becomes art and art becomes function when fundamental principles are utilized to dictate surgical practice. Most important, the risk for inadvertent thermal injury during electrosurgery can be minimized by a sound comprehension of the predictable behaviors of electricity in living tissue.Guided by the Hippocratic charge of primum non nocere, the ultimate aim of energy-assisted surgery is the attainment of anatomic dissection and hemostasis with the least amount of collateral damage and subsequent scar tissue formation.Ideally, the surgeon's final view of the operative field should accurately approximate the topography discoverable after postoperative healing. Despite the continued innovation of products borne to reduce thermal damage and then marketed as being comparatively safer, it is the hands and mind of the surgeon that serve to preserve tissue integrity by reducing the burden of delayed thermal necrosis and taking steps to prevent excessive devitalization of tissue. Regardless of the chosen modality, the inseparable and exponentially linked elements of time and the quantity of delivered energy must be integrated while purposefully moderating to attain the desired tissue effect. Ultimately, the reduction of unwanted thermal injury is inherently linked to good surgical judgment and technique, a sound comprehension of the applied energy modality, and the surgeon's ability to recognize anatomic structures within the field of surgical dissection as well as those within the zone of significant thermal change.During the use of any energy-based device for hemostasis, out of sight must never mean out of mind. If the bowel, bladder, or ureter is in close proximity to a bleeder,they should be sufficiently mobilized before applying energy. Thermal energy should always be withheld until an orderly sequence of anatomic triage is carried out.Whenever a vital structure cannot be adequately mobilized, hemorrhage is preferentially controlled by using mechanical tamponade or suture ligature.

Treatment of fibroids via uterine artery occlusion (uterine artery embolization and Doppler-guided uterine artery occlusion): potential role in today's armamentarium.

Uterine fibroids, the most common benign tumors of the female reproductive system, are the most common indication for hysterectomy. However, this procedure is not the ideal treatment for many women including those who desire to preserve their fertility or simply do not want to undergo surgery. New technologies and surgical innovation provide treatments that are less associated with morbidity such as uterine artery embolization, magnetic resonance imaging-guided focused ultrasound, and laparoscopic uterine artery occlusion. This manuscript will discuss the putative mechanism of action and clinical application of uterine artery occlusion using Doppler-guided Uterine Artery Occlusion, a new investigational treatment modality for uterine fibroids.

Bipolar electrosurgery: convention and innovation.

Bipolar electrosurgery is part of the customary gynecologic surgical armamentarium providing isolated thermal effects and blood vessel occlusion. However, end points are not always predictable as hemostasis may require contiguous applications and thermal damage can significantly expand beyond the target zone. Unintentional transection of a patent vessel cannot be entirely reduced. Recent advances in bipolar technology provide more predictable vessel occlusion with less thermal damage. To date, there are 3 novel bipolar platforms, using either impedance feedback from the operative site to moderate output as pulsed current with lower voltage or by local regulation using nanotechnology within the jaws.

Hysterectomy in the 21st century: different approaches, different challenges.

The final decision to perform a certain method of hysterectomy customarily mirrors experience and level of comfort with a particular surgical approach in the context of the patient's condition and indication for surgery. Given the morbidity and recovery associated with a laparotomic incision, every effort should be made to avoid abdominal hysterectomy. The best available evidence points to the advantage of the vaginal approach over other methods of hysterectomy for benign conditions. Regrettably, the state of education in residency programs is not providing a level of surgical competency to meet this charge. Whenever vaginal surgery is not an option, laparoscopically assisted hysterectomy offers the best alternative. Although the promises of supracervical hysterectomy have yet to be demonstrated, laparoscopic supracervical hysterectomy may offer the least morbid alternative to vaginal hysterectomy.

Electrosurgery-induced generation of gases: comparison of in vitro rates of production using bipolar and monopolar electrodes.

STUDY OBJECTIVE: To compare rates of production of gases generated by VersaPoint bipolar hysteroscopic vaporizing electrodes using normal saline and monopolar vaporizing electrodes using 1.5% glycine. DESIGN: In vitro study (Canadian Task Force classification II-1). SETTING: Laboratory. MATERIAL: Bovine cardiac muscle. INTERVENTION: Fresh morbid bovine cardiac muscle was fully immersed in normal saline for the bipolar system and in 1.5% glycine for monopolar systems. Loop and bulk vaporizing electrodes were activated by radiofrequency electrosurgical units (ESUs) appropriate for each system, at standard powers and at settings higher than those in clinical use. MEASUREMENTS AND MAIN RESULTS: Rates of gas production were calculated and data analyzed by analysis of variance. For bulk vaporizing electrodes, the highest gas production rates at standard settings occurred with monopolar electrodes and the Force 2 generator at 300 W, and the Force FX at 200 W. At slightly higher than standard 200-W settings, the VersaPoint bipolar bulk vaporizing electrode was associated with lowest gas production rates in this category. Although there were statistically significant differences between loop electrodes, the magnitude remained small at similar ESU settings, and differences are thought to be clinically insignificant. CONCLUSION: Rates of gas production in this model appeared to vary most with ESU power output settings and relatively little with electrosurgical modality (bipolar or monopolar).