How to use electrosurgery and ultrasonic surgery correctly?

The emergence of energy devices is an inevitable result of the development of science and technology. It can improve the efficiency of surgery, reduce intraoperative blood loss, and transform previous transabdominal surgeries into laparoscopic or robotic surgeries. However, once you do not know the principles and human anatomy, you will use them indiscriminately. It will lead to irreversible disaster, which is much more serious than the damage caused by non-energy equipment. First, let’s make a brief analysis and explanation of the current common energy devices.

Ordinary monopolar electrosurgical knife
It uses a complete circuit to cut and coagulate tissue, which consists of a high-frequency generator in a high-frequency electrosurgical unit, a patient plate, connecting wires and electrodes.
In most applications, current passes through the patient through active leads and electrodes, and then returns to the generator of the electrosurgery via the patient plate and its leads.

skills:
1. Don’t open it too wide. The actual energy output of each instrument or the same electrosurgical device varies in different states. Generally, electrocution and electrocoagulation do not exceed 40 watts. Principle: Adjust to the minimum power that can complete the operation. For the operation of liver metastases during ovarian cancer debulking surgery, the electrocoagulation of liver tissue can generally be turned on to 100 watts.
2. The electric knife is not a knife. The principle of electric cutting is to cut by sparks caused by intermittent discharge, so the electric knife cannot be used as a knife. Just keep a small distance between the electric knife and the tissue to generate uniform small sparks. Do not press the electrosurgery forcefully onto the tissue to cause tissue damage.
3. Organizational pull is very important. The skin flap must be raised at a 45-degree angle to allow a certain gap in the tissue. The electrosurgical knife walks within the gap so that the anatomical levels are clear.
4. Electrosurgical walking speed control. Too slow and the tissue is damaged; too fast and the vital tissue is damaged.
5. Use electrocoagulation to stop bleeding. Generally, lifting the blood vessel clamp with the help of a blood vessel clamp is effective in stopping bleeding.
6. Patients with subcutaneous fat hypertrophy should use less electrosurgery to avoid tissue liquefaction and necrosis, which will lead to inability to heal the wound.
7. Since the active point of the electric knife is the place with the largest contact resistance, it is necessary to avoid poor skin contact when the ground wire is connected, and the contact should be reliable (the area should be as large as possible) to avoid burns!
8. Do not try to cut open the removed specimen. Since there is no circuit formed, there will be no reaction. If there is a reaction, it will be the surgeon himself, and the surgeon will be shocked!
9. For some places with rich muscles, if you want to cut off the muscles, using electrocoagulation to cut will cause less bleeding. The reason is that electrocoagulation will not cut too fast, and the current is small, and there is enough time to "char" the muscles to stop bleeding. When there is a lot of tissue clamped and electrocoagulation cannot be achieved, the use of electrocution to stop bleeding will achieve good results.
10. If you use an electric knife for deep tissue, try to use a long-handled one with only the tip exposed to prevent the exposed metal tip from damaging blood vessels, nerves and other adjacent structures.
11. Be careful not to accidentally damage the epidermis with the electric knife. Try not to cut the subcutaneous tissue with the electric knife. Use a scalpel to cut the subcutaneous tissue, and then use electrocoagulation to stop bleeding. In some areas where there is not a lot of bleeding, you do not need to cut with an electric knife. You can use scissors or a lancet to cut.
12. When removing the internal fixation, the electrosurgery should not touch the internal fixation, especially the internal fixation of the spine. The electrified electrosurgery may damage the dural sac, nerve roots or spinal cord, resulting in neurospinal injury or even paraplegia.

Note: Monopolar electrosurgery cannot directly coagulate and cut the blood vessels of the uterus and ovary, which may easily lead to bleeding. After bleeding, the anatomical structures cannot be clearly identified and may damage adjacent tissues such as ureters, bladders and intestines. The blood vessels of the uterus and ovaries can be treated using bipolar coagulation or suturing.

Features of ordinary bipolar electrocoagulation:
1. There is no need to form a circuit with the patient's body. It only has the function of electrocoagulation and hemostasis, not cutting.
2. The coagulation site is between the two electrodes.
3. Compared with the electrocoagulation function of monopolar electrosurgery, it is safer and has better coagulation effect.
4. When dealing with uterine blood vessels or pelvic infundibular ligament, first use a vascular clamp or vascular forceps to temporarily block the blood flow and then perform electrocoagulation, which will have better results.
5. Note that the intermittent electrocoagulation method is more effective than the continuous electrocoagulation method.

Ligasure ligation speed vessel closure system
You can call Ligasure a smart bipolar plus cutting blade, or a computer feedback-controlled bipolar electrosurgical system (feedback-controlled bipolar). Ligasure is an improvement on the ordinary bipolar electrosurgical system.
Although the voltage across the Ligasure blade is much lower than that of traditional bipolar electrosurgery, the contact area between the Ligasure blade and the tissue is significantly larger than that of traditional bipolar electrosurgery, and therefore, greater current can be allowed to pass.
The host can feel the electrical impedance of the target tissue between the blades through the feedback control system. When the tissue is coagulated to the optimal level, the system automatically cuts off the power and a beep sounds to remind you that coagulation is complete.
The Ligasure cutting and closing system applies real-time feedback and intelligent host technology to output high-frequency electric energy, combined with the pressure between the electric blades, to melt and denature the collagen and fibrin of the blood vessels to be cut, and fuse the blood vessel walls to form a transparent zone, creating a permanent The lumen is closed.
The Ligasure ligation rapid blood vessel closure system is different from ordinary bipolar in that it has a blade switch. Pressing this switch can push out the built-in blade to cut off the coagulated tissue.

The advantages of Ligasure are:
1. Close blood vessels with a diameter of less than 7mm (theoretical value only);
2. No excessive separation is required when closing blood vessels in tissues;
3. The closed band formed can withstand pressure exceeding three times the normal human systolic blood pressure;
4. Fast closing speed, no smoke, and does not affect the surgical field of vision;
5. There is no odor and no carbonization when closed, so no sutures, titanium clips and other foreign matter remain after closing;
6. When closed, the local temperature is not high, the heat diffusion is small, the heat conduction distance is only 1.5~2mm, and there is no damage to the surrounding tissue.
Ligasure is more efficient than traditional bipolar electrosurgical surgery and is particularly suitable for laparoscopic and open tumor surgery, greatly improving the safety of surgery.

Note: The clamped tissue should be less but not too much, preferably 1/2 to 3/4 of the length of the blade. The pelvic infundibular ligament should be solidified twice before cutting. If the uterine blood vessels are very well exposed, , first use a vascular clamp or vascular forceps to temporarily block the blood flow, and you can coagulate and cut at one time. Of course, the treatment should be based on the actual situation of the patient during the operation.

Ultrasonic scalpel
The application principle of ultrasonic scalpel is to convert electrical energy into mechanical energy through a special conversion device. The mechanical energy transmitted in the form of sine waves acts on the metal cutter head at the front end, causing the cutter head to produce mechanical oscillations of 50 to 100 μm amplitude, thereby generating friction heat. And the shearing force to both sides due to tissue tension vaporizes the water in the cells of the contacted tissue, breaks the protein hydrogen bonds, denatures the protein, and the tissue is coagulated and then cut. The application of ultrasonic scalpel in laparoscopic surgery has obvious advantages.
Ultrasound scalpel causes far less damage to surrounding tissues than electrosurgical scalpel. Its precise cutting effect allows it to safely separate and cut next to important organs and large blood vessels. The less smoke and less eschar makes the laparoscopic surgery field clearer and more effective. The operation time is shortened, and no current passes through the human body, making the operation safer and reducing the occurrence of complications.
The treatment of intra-abdominal patchy adhesions and mesentery, which are difficult and time-consuming with electrosurgical scalpel, has become easier to deal with after using ultrasonic scalpel, which reduces the difficulty of surgery and the amount of intraoperative bleeding, and is more in line with the tumor-free principle of tumor surgery. .
When in use, the temperature of the ultrasonic scalpel head is lower than 80°C, the surrounding propagation distance is less than 5 microns, there is very little smoke, eschar, no sparks, and no electrophysiological interference to the body. Compared with the electrosurgical knife commonly used in ordinary surgeries, the ultrasonic knife has the advantages of precise cutting, firm hemostasis, and strong controllability. Its safety and effectiveness are superior, so it is more advanced.

Factors affecting the hemostasis effect of ultrasonic scalpel cutting:
1. The working gears of the ultrasonic scalpel: high-grade - cutting; low-grade - coagulation; coagulate first and then cut;
2. The tension of the tissue when cutting with the ultrasonic knife: there is no vascular tissue, the tension is increased and the cutting speed is fast. Rich vascular tissue, reducing tension and good coagulation effect;
3. The pressure of the ultrasonic knife to clamp the tissue: high pressure - fast cutting; low pressure - good hemostasis;
4. Choose the working surface of the ultrasonic knife: sharp surface - fast cutting; blunt surface - good hemostasis.
5. Try to use the first 1/3 to 1/2 of the ultrasonic knife head to clamp the tissue, so that the tissue in the jaw can be stopped bleeding and cut off at one time.

Common improper or wrong operations of ultrasonic scalpel:
1. Operation without direct vision;
2. Operate the working blade close to the important organs: fully lift the tissue, keep the working surface away from the tissue, or the non-working surface is close to the important tissue;
3. Clamping large pieces of tissue: fast, easy to bleed, slow, produces a lot of fog, and cannot be finely dissected;
4. Contact with metal or bone during excitation: leading to breakage of the blade or tissue damage;
5. Long-term excitation: try to <7s for one excitation;
6. Clamp a small amount of tissue for empty excitation: The cutter head is separated during the test, and the clamped tissue is moderate;
7. Work with scabs for a long time.

Note: When separating the ureter with ultrasonic scalpel or ordinary monopolar electrosurgery, it is extrathecal (ureteral) dissection, and when dissecting lymph nodes, it is intrathecal (blood vessel) dissection.
Knowing the principles of using weapons, using the experience of the predecessors and combining it with one's own reality during surgery, operating in the anatomical gap like a butcher undressing a cow, minimizing damage and pursuing bloodless surgery are the lifelong goals of every surgeon. Finally, don’t forget: the safest knife is a lancet!
Don’t panic if there is bleeding during the operation. Compression to stop the bleeding is very important. If you can see the bleeding point clearly, you can use bipolar electrocoagulation to stop the bleeding, but the best way to stop the bleeding is to suture!
When working with energy instruments, it is best to let the assistant use the suction device to work at the same time. This can effectively expose the field of view of the surgical area!

Any device that uses electrical energy will generate a large amount of heat during use, so remember that these energy devices must be within your field of vision at all times during surgery to avoid burns to the intestines and other tissues caused by the device leaving your field of vision. And it was not discovered during the operation!