Basics of Electrosurgery

and
Argon Plasma Coagulation

Joo Ha Hwang, MD, PhD

July 26, 2013

 Learning Objectives

History of Electrosurgery
Discuss the basics of electricity
Discuss the principles of electrosurgery in endoscopy
Differentiate monopolar and bipolar modes from
argon beam coagulation
Review clinical applications of electrosurgery in
endoscopy
Describe safety measures for procedures that
incorporate electrosurgery
 Electricity Becomes
Electrosurgery
1923-1926

Christian Erbe, William Bovie &

Harvey Cushing,
Germany 1923
USA 1926
1932 Grant E. Ward
American Journal of Surgery

> An adequate surgical

training is a prerequisite to the
adoption of electrosurgeryIt
little behooves the novice to
take up such a powerful
weapon, dangerous in the
hands of the unskilled.
1978 Glover, et al.

> There is no group of

instruments in the
surgical armamentarium
that is used as frequently
and understood as poorly
as electrosurgery
units.
As clinicians.

Understanding the Principles of Electricity

is imperative
for a safe and efficacious procedure
involving Electrosurgery

Consider the following information:

Principles of Electricity & Electrosurgery 101
Laws of Electricity

It always seeks ground

It always seeks the path

of least resistance

As resistance within the

circuit increases, current
flow decreases.
Basic Electrical Terminology
Power ESU Wattage Value

Circuit - path of current from the

ESU through the patient to the pad,
and back to the ESU.

Impedance (resistance) the tissue

being treated. Has varying
characteristics.

Voltage - electrical force pushing

the current around the circuit,
through varying degrees of tissue
resistance.
Electrical Terms

> Circuit - pathway for the uninterrupted

flow of electrons

> Current - flow of electrons, amperes

> Resistance Obstacle to the flow of current,

ohms (impedance AC)
> Voltage - force pushing current
through the resistance, volts

> Energy Joules [watt-sec]

> Power Watts [joule/sec]

> Frequency Hertz [cycle/sec]

Factors That Influence Tissue Heating

Heating increases directly with:

resistance (ohms) offered by the tissue to
current flow
the measure of current flow (amps)
the duration of time that the current flows
2
Total heat = resistance x amps
watts = volts x amps
A good conductor with low resistance will
not undergo much heating
 Resistance ~ Impedance
C I
O N
N GI Mucosa Skin Bone S
D U
U L
C A
T Blood Muscle Fat Plastic T
O O
R R
S S
Tissue Impedance Varies with H20 Content
Scar Tissue, Lung,
Adhesions

Mesentary,
Brain

Bowel
Fat
Resistance

Gallbladder

Liver, Oral
Cavity

Muscle,
Kidney, Eye

Most Least
Water Content
Forms of Frequency

Low
High
Effects of Low Frequency

Nerve Stimulation
Muscle Stimulation
Pain
Cardiac Arrest
Transformer
 High [Radio] Frequency
Alternating Current

Electrosurgical Generators

> GOOD Only thermal effect

High frequency alternating current for

cutting and coagulating tissue
350 kHz
Circuit Modes: Monopolar

Monopolar
= polypectomy
= sphincterotomy
= needle-knife
= APC
Current conducted by body
Grounding pad necessary
 Current Density
Concentration of current per unit of tissue
The most controlled surgery results when the highest
density of current is delivered to the smallest area of
tissue
Techniques to maximize current density
minimize wire contact with tissue
use small diameter snares
use devices with thin wires
Minimize current density at ground pad to reduce the
risk of a local burn (large surface area)
Monopolar Devices

Snare polypectomy
Sphincterotomy
Needle-knife
what actually
a snare
does

Current density results from constricting

tissue
The tighter the snare the
more focused the energy
[higher current density]

Polyp

Snare

Stalk
Circuit Modes: Bipolar

Bipolar
No current through the body
No grounding pad
Device carries delivery and
return electrodes
Only effect is on contact
tissue
Bipolar Devices
Hemostasis
Electrohydraulic
lithotripsy
ESU Thermal Effects on Cells
Temp Tissue Effect

104F 40C Reversible

cellular trauma

120F 49C Irreversible

cellular trauma

158F 70C Coagulation

(Dessication)

212F 100C Cutting

392F 200C Carbonization

ESU Thermal Effects

CUT
Cutting requires a spark - a
minimum of 200 volts

Rapid vaporization
Cell membrane ruptures creating
a steam bed
Steam separates or cuts the cell
apart from adjacent cells

No mechanical force needed

ESU Thermal Effects

COAG
Coagulation of proteins

Slow vaporization of cellular

liquids and vascular occlusion

Desiccation and shrinkage

Devitalization of tumors and

lesions. Higher voltage than CUT.
 CUT, COAG and BLEND

Cut and Coag are two separate duty cycles!

Cut is always designated by the color YELLOW!

Coag is always designated by the color BLUE!

A BLEND is a cut function and can only be

activated by stepping on the CUT (YELLOW)
pedal of the ESU footswitch.
Voltage Standard Generator
600
Coag
550
Blend 6% on
500
50% on 94% 0ff
450
50% off
400
Pure Cut
350
100% on
300
250
200
150
100
50
0
Time
0 1 2 3 4
Electrosurgery Modes
 Electrosurigical Generator Modes

Coagulation - mostly desiccation;

maximum hemostasis
commonly used for polypectomy
Cutting - little desiccation or coagulation
Blend - mixture of coagulation and cutting
blend 1: mostly cut (sphincterotomy)
blend 2: intermediate
blend 3: mostly coagulation
 Common Therapeutic Electrosurgery in
Interventional Gastroenterology

Polypectomy
Papillotomy/Sphincterotomy (ERCP)
Endoscopic Mucosal Resection (EMR)
Contact Bleeding Control (Tamponade)
Non-Contact Bleeding Control (APC)
Ablation (APC, RF)
Polypectomy

Cut (Pure or Blend) & coag

(YELLOW and BLUE pedals)

Coag only (BLUE pedal only)

Operator should close the

snare
 Papillotomy/Sphincterotomy
(ERCP)

Cut (pure) w/Needle Knife (YELLOW PEDAL- Tapping)

Cut and coag (YELLOW and BLUE PEDAL Tapping)

Endo Cut (ERBE only) (YELLOW PEDAL NO Tapping)

 Argon Plasma Coagulation - APC

APC is a non - contact

monopolar coagulation
application using the BLUE
pedal
Argon Plasma Coagulation

> Electrosurgical generator

> Argon Plasma

Coagulator control
unit

> Probe
 Argon Plasma Coagulation
APC is generated by electrically charging
argon gas to ionize it, forming a plasma.

Electrode
Argon Plasma

Argon Gas

Gas Flow in Probe

Self-Limiting
Mucosa
Desiccation Zone

APCs primary advantage is being NON-CONTACT.

Argon Plasma Coagulation
Three conditions:
Sufficient voltage

Proximity to tissue

Conductive tissue
Advantages of APC

Non-contact application
Even, uniform hemostasis and
coagulation

Smoke is reduced (argon gas

displaces oxygen)

Current seeks areas of

better conductivity
Shorter procedure
times

Thinner eschar
 Clinical Applications
APC for Gastric Antral Vascular Ectasia
(GAVE or Watermelon Stomach)

Before

During
APC

Post APC
Clinical Safety
 Generator Settings

The FDA view settings

the same way as writing a prescription.
 Generator Settings

A physician should be determining settings.

Settings are influenced by:

Co-morbid conditions
Pathology type, size, invasiveness
Degree of thermal injury desired
Patients medications and lab results
Tissue hydration observed
Treatment mode availability
Type and effectiveness of prep
 Generator Settings

The physician and staff need to verbally

CONFIRM settings before activation.
Dispersive Electrodes
(grounding pads)
Dispersive Electrodes

GI Endoscopy Pad Placement

> Well vascularized area

> Shortest circuit possible

> Optimum on flank

> Alternatives Thigh or Arm

Dispersive Electrodes

Pad Placement Exceptions

> Fluro cases

-ERCP
-Pulmonary

> Pacemaker/ ICD Patients

- Draw current AWAY from
Pacemaker
- Opposite side of body,
lower extremity if possible
Dispersive Electrodes

The Dispersive Electrode

Should NOT Be Placed Over:

> Bony prominences

> Scar tissue- including Tattoos

> Skin/Scars over an implanted metal

prosthesis

> Hairy surfaces- shave if necessary

 Alternate Site Burns

Electricity Always Seeks The

Pathway of Least Resistance.

Alternate Site Burn

Pad Site Burn

Pacemaker, ICD
Basic Safety:

> Use of HF current may damage

the pace-maker. Use Bipolar
when possible.
> Keep 15 cm between the active
electrode and any EKG electrode.

> Have resuscitation equipment at

the ready - DOCUMENT

> Notify Cardiology Fellow

> DEACTIVATE ICDs reactivate

immediately after procedure
Bowel Preps
What should nurses
know about preps?
> Bowel explosions from marginal
preps can occur with ANY
monopolar electrosurgery

> The risk is from trapped

hydrogen and methane gases

> Bowel explosions are being

reported more often, as the
number of colonoscopies
increases.

> Gastric explosions are rare, but

possible
APC Use
Emphysemas, Embolisms
and Perforations:
> Emphysema gas forced into the
bowel wall may migrate to other areas

> Embolism gas which is blocking a

blood vessel

> Perforation interruption in bowel wall

gas may collect in a cavity

> Argon absorption by the body

APC Use
Scope Technique

> Purge at least twice before placing the

probe in the scope

> Advance the tip of the probe until the

first black line is visible on the monitor

> Leave the probe stationary- move the

SCOPE