Energy options in gynecologic surgery

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Now, we can use common-sense methods to minimize destruction from conventional bipolar electrosurgery. And we can watch tissue, and when it becomes white and when it becomes dry and doesn’t emit steam any more, we can feel confident it’s ready to cut. So we use color and we use tissue behavior to dictate when we’re done, rather than to overcook tissue through fear and anxiety that we may have a patent lumen. We can also pulse current because current can be applied and, in between the pulses, the energy can be dissipated by the circulation of the blood, by convection and conduction of heat. We also can take the sides of our instrument and realize that when you take tissue and you grasp it and you crush it, you end up having wide thermal margins.

So look at this little bleeding pedicle after salpingo-oophorectomy. And the attack is to take a tack from the right side contralateral and use a tamponade desiccate, no grasping of tissue. This is an entirely different method of hemostasis than grabbing a pedicle, crushing it, and desiccating it. So whenever we can tamponade desiccate, almost like a trampoline—tamponade desiccate, tamponade desiccate—we basically have almost no thermal penetration and no thermal margins.

And, of course, both you and I get panicked when we see active bleeding. And what we must do is we must resist this immediate desire to stop bleeding with energy. And so when we have active bleeding, first and foremost as surgeons, we have to find out where we are and then we’ve got to stop everything mechanically.

And if you see any advanced laparoscopic surgeon deal with adversity in hemostasis, you will see every one of them grasp or put tension on a bleeder to tamponade, time out, take a breath, find out where you are, and then, and only then proceed. And if you see there’s something relevant that’s near, whether it’s uterosacral ligament, ureter, bladder, bowel, you will mobilize that tissue with the appropriate relaxant incisions. And then and only then do you bring in the heat. And even then, you might be conservative and be pulsatile desiccating versus pure desiccating.

Now, this is the background of where we’ve been. And I and a number of colleagues have been talking about this, writing about this, for many years. And to our pleasure, I don’t think in response to anything we’ve done, industry has come forward with amazing innovation and research outputs that have changed the face of bipolar electrosurgery. And we’re going to discuss a few of these evolutionary steps as they contrast to traditional bipolar electrosurgery to help you understand what’s available today.

We all remember a number of years ago that we had a 10-mm device that finally came out that was like a waffle iron and we had a blade that came down. So now for the first time, we had a multifunctional, multiple-purpose instrument to be placed on a trocar that could coagulate and cut with a mechanical blade. Many things followed that innovation. In response to everything we know about voltage—you remember voltage is destructive, is force; voltage is the wrong side to be on the generator, if you can help it. These all became now relatively constant, low-voltage devices. So the high-voltage equation has been erased from bipolar electrosurgery with use of these devices. And for the first time, rather than a generator autonomously just delivering energy as you push on the pedal, now the generator is talking to the tissue and the instruments all send back information about the resistance impedance of the tissue. So now, the amount of energy that’s created, the amount of current that’s delivered by the instrument, is completely moderated to what’s needed to desiccate the tissue, so you get more uniform effects. And as we’ve advocated for pulsing, for cooling, pulsing does 2 things. Not only does it help the tissue cool, it also allows the generator in between pulses to register the information and now respond. So the introduction of pulsing gives the generator a chance to communicate with the tissue. And with this tissue cooling, you also get delivery of energy that’s more uniform. And finally, if you remember the last point on my conventional slide, which was we’re all happy, everything’s wonderful, now we cut the vessel and we’ve got the little red course spurting in our face. We now have technology, that when we even get audible feedback, or we are integrated with the device, and we get visual proprioceptive feedback and we decide to push the button, push the blade, we in fact have reliable, consistent hemostasis. We’ve changed the whole equation with the evolution of bipolar electrosurgery. So look at this vessel now. We’re talking about intima-to-intima fusion from vessel sealing.

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