Energy options in gynecologic surgery

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Now, one of the pieces of these devices is that they’re all approved for vessels up to 7 mm. And this is well beyond anything that you or I are going to experience and need in the pelvis.

Another nuance is when you take a blood vessel and you compress it with low energy, ie, low voltage and high current. You need to do a little trick if you want a great seal. And a great seal is also to release your tension just a little bit on your pedicle and then to apply the energy. So we allow that lower energy to do an intima-to-intima fusion, which sometimes is physically overcome by too much torsion or traction on your pedicle.

So you would expect to see some promises here. And the promises are, hopefully, natural and you’ll see them each time. We don’t have tissue sticking, because that was from high-voltage carbon. We don’t have it anymore. Overheat the tissue, get plume and smoke. Your environment gets muddled. Reduced thermal spread, because now we’re just delivering the right amount of energy that’s needed to attain the task. And, ultimately, we have consistent vessel sealing. This is almost the adverse of that slide that I showed with the generic concerns that we have as laparoscopic and laparotomic surgeons.

Now, one of the advents that was very important in the last several decades was an understanding of the whole idea of tissue welding. And then, in fact, it realized that you could use a certain amount of pressure—very, very high compressive force. If you could deliver that with a small amount of voltage and a small amount of energy, temperatures less than 100°, for the right amount of time you could literally transform collagen and elastin into a tissue glue that had tremendous sustaining powers that could overcome any high or superphysiologic systolic pressures.

So we look at this vessel, which is vessel seal. Incredible difference from the one that we saw before. And here we see true intima-to-intima sealing. And look at the margins, the heat thermal affects how dramatically they differ in these 2 vessels.

So I want to finish this up by talking to you about the 2 devices that are in my armamentarium, because they’re complementary, and especially about this new technology called ENSEAL®. And, as I said, there’s been an evolution of devices. But with this particular dedicated advanced bipolar device, there are 3 unique features that, to me, are very exciting because they open up new possibilities and new promises in the context of delivery of energy to the tissue and regulating the thermal effect. And I’m going to tell you about each one separately. One is basically an intrinsic control that’s in the device that actually determines the temperature at which the tissue is heated. And we’ll talk about that. And it regulates the energy delivery. Another is a unique configuration. And I think you’re all going to be immediately excited about this when you see this invention that was thought of by the inventor. It gives you this, for the first time, a uniform compression from the heel to the tip of the instrument. And lastly, there’s a jaw design with the electrodes that help keep the current from spreading laterally into the tissue that gives you a consistent effect.

So let me try the first one with you, and it may be the most difficult to explain, but I think it’s the most interesting. As I told you, there was no way to moderate output in conventional bipolar electrosurgery. Push your foot on the pedal, deliver the energy, and if it was a blow torch of voltage, it was a blow torch of voltage. That’s what you get with the Kleppinger. Now you use more advanced devices. The generators are communicating with the tissue and only putting out what it needs. Now for the first time, it’s regulated at the jaw.

So, in fact, the thermal effects in the ENSEAL device are regulated by the compositional electrical characteristics of the jaw. And I’ll explain to you how this is. The jaw basically is plastic, and plastic is a nonconductor. And the reason that this conducts electricity is because it’s been impregnated with small spears of conductive particles. And these conductive particles can control energy delivery through a very, very unique mechanism. So look at the picture on the left and then look at the one on the right in this lower diagram. You’ll notice on the left that the particles are lined up and they’re close together. They’re in the plastic, and this plastic very comfortably is going to conduct the electricity. As the plastic heats up, the spirals, these conductive particles are going to move farther apart. And as they move farther apart, guess what happens? It becomes nonconductive. So if you can take this other step and realize that the jaw is not uniformly one temperature, there may be several hundred zones along the jaw but at different temperatures, in fact, like thermostats, are turning on, turning off, turning on, turning off, in response. And the end result is that you get uniform temperature because it’s going to turn off at approximately less than 100°C.

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