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Energy options in gynecologic surgery

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Now, let’s take a look at this picture and focus in on the picture on the right. And when I first saw this picture, I really didn’t notice anything very significant until someone really educated me and pointed out what really happens when you take a vessel of substantial size, you grasp it, and you compress it with a conventional Kleppinger bipolar forceps. And then take a look, in fact, how hemostasis is attained in that vessel. Well, the first thing you notice is that it’s shrunken, and it shrinks because when you heat collagen and elastin, it’s like an accordion—it shrinks up about 40% to 50% of volume. When you heat collagen, it just shrinks up like a Slinky. So you have shrinkage of the vessel wall. But you’ll also notice there’s a large proximal thrombus there. But if you’re really a careful observer—and as I’ve said, I missed this the first time I looked at it—the lumen is still apparent. In fact, the lumen is patent. And when we coagulate and desiccate vessels of significant size with a Kleppinger bipolar forceps, regardless of what your generator settings are, you have a vessel that essentially has a patent lumen. Now, as surgeons in the pelvis, we can get away with this because our pulse pressers in general are very low, because we’re down the vascular tree from the central pump. But you are a general surgeon, and you saw this and you realized you have to work on vessels like the gastric artery that has significant high systolic pulse pressures, you would realize you could not rely upon this technology, and we can understanding looking at this, for our general surgeon colleagues really didn’t become interested in bipolar electrosurgery until they had further assurances that it would be more effective.

Now, this slide here is a summary of what are my experiences with conventional bipolar electrosurgery. And I think every surgeon who’s watching this and is honest about their work experiences these on a daily basis using conventional bipolar electrosurgery. I don’t know how many times I’m going to overlap. I’m not sure you do, either. On 1 pedicle, 2 pedicles, right side, left side. We have variable numbers of compressions to attain the task. No automation, no regulation of what we’re doing. How long do I apply the energy? How long do you apply the energy? How long do I apply the energy on the right? And then how much do I apply on the left? And then you know and I know, we look at the thermal margins—we have spread. We don’t have total control over our thermal margins, especially using conventional bipolar electrosurgery. And most importantly, you’re satisfied, I’m satisfied, our vessel looks like a rope, it’s shrunken down, it looks completely desiccated. We now take our scissors and we cut it and it bleeds. And you have your little red dot that pulsates, and you realize that after all that work, you’ve got to go and work on it again. So these, I think, are generic, universal problems we have with conventional bipolar electrosurgery.

And I also ask you the question, What’s the margin of safety? Yes, we know that the current flows between the 2 jaws. No question the current goes nowhere else. There’s no diversion of current that occurs with bipolar electrosurgery. It cannot happen. But there’s something else with bipolar that’s problematic—and that is the production of steam and thermal effects.

So when you see this picture, you have to ask yourself the question, If the electricity just goes from one jaw to the other, what is this white that is blooming? And all of you who have done tubal coagulation procedures for a female sterilization have seen, on the application of energy with Kleppinger bipolar forceps, a little puff of steam and then, all of a sudden, the whole mesosalpinx rises and drops. And, of course, that’s the filling of the broad ligament with steam. The steam rises, and it gets absorbed, it drops. So we create a huge plume of steam. Remember what steam does to cells? Steam is very percussive—it explodes the cells and it spreads heat. So it’s very destructive.

So one way we avoid making too much steam, if we’re doing conventional bipolar electrosurgery, is we never use ammeters to direct the surgical endpoint. We use ammeters to direct the surgical endpoint for tubal coagulation because we want napalm to be delivered to the mesosalpinx. That’s the opposite of what we want, of course, when we’re doing surgical dissection of the pelvis. So if you use an ammeter to direct your endpoint in bipolar electrosurgery, you are maximizing steam production and therefore maximizing lateral thermal injury.

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