SURGICAL MODALITIES

SURGICAL SURGICAL MODALITIESMODALITIES

EL PASO COMMUNITY COLLEGEEL PASO COMMUNITY COLLEGE

SURGICAL TECHNOLOGY SURGICAL TECHNOLOGY PROGRAMPROGRAM

MARGARET M. RODRIGUEZ, MARGARET M. RODRIGUEZ, INSTRUCTORINSTRUCTOR

UNIT TITLESUNIT TITLES

ELECTRICITY, ELECTROSURGERY ELECTRICITY, ELECTROSURGERY AND FIRE SAFETYAND FIRE SAFETY

IONIZING AND NON-IONIZING IONIZING AND NON-IONIZING RADIATIONRADIATION

ULTRASONIC AND HYDRODISSECTION ULTRASONIC AND HYDRODISSECTION DEVICESDEVICES

ENDOSCOPY/MINIMALLY INVASIVE ENDOSCOPY/MINIMALLY INVASIVE SURGERYSURGERY

UNIT TITLESUNIT TITLES

MICROSCOPES AND MICROSURGERYMICROSCOPES AND MICROSURGERY

ROBOTICS AND GUIDED IMAGERYROBOTICS AND GUIDED IMAGERY

I. ELECTRICITY, ELECTROSURGERY I. ELECTRICITY, ELECTROSURGERY AND FIRE SAFETYAND FIRE SAFETY

GLOSSARY OF TERMSGLOSSARY OF TERMS

ELECTRICITY – a ELECTRICITY – a fundamental entity of fundamental entity of nature usually used as nature usually used as electric currentelectric current

CONDUCTORCONDUCTOR

Any substance, medium, or material that allows Any substance, medium, or material that allows the transmission of electricity (flow of free the transmission of electricity (flow of free electrons)electrons)

Examples: metals, carbon, salt water, humansExamples: metals, carbon, salt water, humans

INSULATORINSULATORA medium that does not allow the transmission A medium that does not allow the transmission of electricity by inhibiting the flow of electrons.of electricity by inhibiting the flow of electrons. A non-conductive material such as rubber, glass, A non-conductive material such as rubber, glass,

porcelain, or wood.porcelain, or wood.

ELECTRICAL CHARGEELECTRICAL CHARGE

ALL MATTER CONSISTS OF ATOMSALL MATTER CONSISTS OF ATOMS

ATOMS ARE COMPOSED OF:ATOMS ARE COMPOSED OF: Protons – positively charged particlesProtons – positively charged particles Neutrons – particles with no charge, neutralNeutrons – particles with no charge, neutral Electrons - negatively charged particles Electrons - negatively charged particles

ELECTRICAL CHARGEELECTRICAL CHARGE

When electrons move from one atom to When electrons move from one atom to another, an imbalance occurs.another, an imbalance occurs.

An atom which has lost electrons will carry An atom which has lost electrons will carry a positive charge.a positive charge.

An atom which has gained electrons will An atom which has gained electrons will carry a negative charge.carry a negative charge.

ELECTRICAL CURRENTELECTRICAL CURRENT

THE MOVEMENT OF ELECTRONS THE MOVEMENT OF ELECTRONS THROUGH A CONDUCTORTHROUGH A CONDUCTOR

Example:Example: a light bulb illuminates because a light bulb illuminates because electrons move through the conductor of electrons move through the conductor of wires and metal base to the tungsten wires and metal base to the tungsten filament in the bulb. The filament heats up filament in the bulb. The filament heats up and brightens – producing light.and brightens – producing light.

ELECTRICAL CURRENTELECTRICAL CURRENT

Current Current The rate at which electricity flows.The rate at which electricity flows. Measured in amperes.Measured in amperes.

TYPES OF ELECTRICITYTYPES OF ELECTRICITY

Alternating Current (AC) – a Alternating Current (AC) – a current that periodically current that periodically reverses its direction of flow.reverses its direction of flow. Power from external power plantPower from external power plant

Direct Current (DC) – a current Direct Current (DC) – a current flowing in only one direction.flowing in only one direction. Battery powerBattery power

ELECTRICAL TERMSELECTRICAL TERMS

PATH OF LEAST RESISTANCE - electricity or PATH OF LEAST RESISTANCE - electricity or the flow of electrons will act like water and always the flow of electrons will act like water and always seek a path from highest concentration to lower seek a path from highest concentration to lower concentration via the easiest route.concentration via the easiest route.


CURRENT LEAKAGE CURRENT LEAKAGE - all electricity can - all electricity can leak causing the leak causing the potential for shock.potential for shock.


Ampere – the practical unit of Ampere – the practical unit of current strength.current strength. The amount of current flowing in The amount of current flowing in

a circuit. The rate of flow.a circuit. The rate of flow.

Ohm – the unit of electrical Ohm – the unit of electrical resistance of a conductorresistance of a conductor Measurement of the ability of a Measurement of the ability of a

material to receive flow of material to receive flow of electrons.electrons.


Volt – the unit of electromotive force that moves Volt – the unit of electromotive force that moves electrons through a material. It induces current electrons through a material. It induces current to flow in one direction. to flow in one direction. The higher the number of volts, the more direct the The higher the number of volts, the more direct the

currentcurrent

Voltage – the potential energy of electrons. Voltage – the potential energy of electrons. Electromotive force of an electric current Electromotive force of an electric current expressed in volts.expressed in volts.


Resistance – the opposition to Resistance – the opposition to the passage of a current.the passage of a current.

impedes or restricts the flow of impedes or restricts the flow of electronselectrons Measured in ohmsMeasured in ohms


GENERATOR – creates a force or voltage and GENERATOR – creates a force or voltage and moves electrons from one point to another.moves electrons from one point to another. Like a plumbing system that utilizes a pump to create Like a plumbing system that utilizes a pump to create

water pressure and move water from one place to water pressure and move water from one place to anotheranother


CIRCUIT - A moving or CIRCUIT - A moving or traveling around. In traveling around. In electricity, the entire course electricity, the entire course traversed by an electric traversed by an electric current. When complete, it current. When complete, it is a closed circuit, when is a closed circuit, when interrupted, it is a broken interrupted, it is a broken circuit.circuit.


POWER – the rate of the movement of POWER – the rate of the movement of electrons from point to point or current flow.electrons from point to point or current flow.

Power = amps or current x voltagePower = amps or current x voltage Power is measured in wattsPower is measured in watts


LOAD – the device that uses the electricity to LOAD – the device that uses the electricity to perform some type of functionperform some type of function

The load can change the amount of energy delivered The load can change the amount of energy delivered from the power sourcefrom the power source

Examples: surgical lamps, ESU, video monitorsExamples: surgical lamps, ESU, video monitors


SWITCH – a device SWITCH – a device used to open or close used to open or close a circuit and controls a circuit and controls the flow of electricity.the flow of electricity.


HOT WIRE – the wire that connects to the HOT WIRE – the wire that connects to the switch. switch. In polarized plugs, hot wire is smaller prongIn polarized plugs, hot wire is smaller prong Often the hot wire is colored redOften the hot wire is colored red


NEUTRAL WIRE – serves as the pathway for the NEUTRAL WIRE – serves as the pathway for the electrons to return to the energy source and electrons to return to the energy source and completes the circuit.completes the circuit. In a polarized plug, it is the larger of the prongsIn a polarized plug, it is the larger of the prongs Wire is often colored greenWire is often colored green


GROUND – the connection of an electrical GROUND – the connection of an electrical current or circuit with the earth through a current or circuit with the earth through a conductor. Safely conveys any leaking conductor. Safely conveys any leaking electrons to alternate path to ground.electrons to alternate path to ground.

Ground wires are often colored blackGround wires are often colored black


Hertz – a unit of electromagnetic wave Hertz – a unit of electromagnetic wave frequency, equal to one cycle of alternating frequency, equal to one cycle of alternating current (AC).current (AC). Each cycle starts at zero – flows in the positive Each cycle starts at zero – flows in the positive

direction, changes to negative, then back to zerodirection, changes to negative, then back to zero


FREQUENCY – the number of waves passing FREQUENCY – the number of waves passing through a given point per one second. This is through a given point per one second. This is measured in hertz.measured in hertz.

TYPES OF ELECTRICITYTYPES OF ELECTRICITY

STATIC ELECTRICITY – caused by friction and STATIC ELECTRICITY – caused by friction and accumulates on objectsaccumulates on objects When two static-bearing objects come in contact, the When two static-bearing objects come in contact, the

one bearing the higher potential discharges to the one one bearing the higher potential discharges to the one with the lower potential creating SPARKS.with the lower potential creating SPARKS.

STATIC ELECTRICITYSTATIC ELECTRICITY

An electrostatic charge or spark between two An electrostatic charge or spark between two objects can occur only when there is no pathway objects can occur only when there is no pathway of conductivity between them; therefore the chief of conductivity between them; therefore the chief aim is to provide a manner of dissipating the aim is to provide a manner of dissipating the static accumulation.static accumulation.


Common environmental hazard Common environmental hazard in the ORin the OR

Does not cause patient shock or Does not cause patient shock or burnsburns

However, its production of an However, its production of an electrostatic spark is its main electrostatic spark is its main hazard because this provides a hazard because this provides a source of ignition for a fire.source of ignition for a fire.


Risks have diminished Risks have diminished because explosive because explosive anesthetic agents are no anesthetic agents are no longer used.longer used.


PREVENTATIVE MEASURES INCLUDE:PREVENTATIVE MEASURES INCLUDE: Good conductive floors prevent accumulation by Good conductive floors prevent accumulation by

providing a pathway of conductivity between persons providing a pathway of conductivity between persons and equipment coming in contact with the static and equipment coming in contact with the static electricity.electricity.


PREVENTATIVE PREVENTATIVE MEASURESMEASURES Safe furniture is made of Safe furniture is made of

electrically-conductive electrically-conductive materials or contact to the floor materials or contact to the floor is made through electrically-is made through electrically-conductive leg tips, casters, or conductive leg tips, casters, or wheels.wheels.


PREVENTATIVE MEASURESPREVENTATIVE MEASURES Operating room floors are cleaned Operating room floors are cleaned

with materials that do not reduce with materials that do not reduce conductivity.conductivity.


PREVENTATIVE MEASURESPREVENTATIVE MEASURES

Avoid wool and synthetic fabrics that Avoid wool and synthetic fabrics that have not received anti-static have not received anti-static treatment.treatment.

Use cotton blankets, towels, etc.Use cotton blankets, towels, etc.


PREVENTATIVE MEASURESPREVENTATIVE MEASURES Use special anti-static liners in Use special anti-static liners in

trash and linen hampers and kick trash and linen hampers and kick buckets.buckets.


PREVENTATIVE PREVENTATIVE MEASURESMEASURES

Maintain room humidity Maintain room humidity level at 50-60%level at 50-60%

STATIC ELECTRICITYSTATIC ELECTRICITYPREVENTATIVE MEASURESPREVENTATIVE MEASURES Dissipate charges by frequently touching metal Dissipate charges by frequently touching metal

surfaces and avoid friction causing activities.surfaces and avoid friction causing activities. example: avoid movement around patient’s head, especially example: avoid movement around patient’s head, especially if his/her hair is uncovered.if his/her hair is uncovered.

ELECTRICAL SHOCKELECTRICAL SHOCK

ELECTROCUTION – ELECTROCUTION – the most severe case the most severe case of electrical shock, of electrical shock, often lethal.often lethal. Occurs when a person Occurs when a person

becomes part of the becomes part of the circuit or closes the circuit or closes the circuit.circuit.


MACROSHOCK – requires a substantial voltage MACROSHOCK – requires a substantial voltage to drive electrons through a highly resistant skin to drive electrons through a highly resistant skin path.path.

Can range from small tingling to electrocutionCan range from small tingling to electrocution

Due to things such as frayed electrical cords, spilling of liquids Due to things such as frayed electrical cords, spilling of liquids on generators, radio with no back covering, or removal of on generators, radio with no back covering, or removal of ground plug.ground plug.


MICROSHOCK – electrical shock below MICROSHOCK – electrical shock below the level of sensation so can come from the level of sensation so can come from undetectable sources.undetectable sources. Requires only a small amount of current but Requires only a small amount of current but

must involve passage through the heart to must involve passage through the heart to cause damage. If so, can also be lethal.cause damage. If so, can also be lethal.

Incidents usually arise from equipment failure, wet Incidents usually arise from equipment failure, wet floors, ungrounded stretchers, or indwelling floors, ungrounded stretchers, or indwelling catheters/monitors, etc.catheters/monitors, etc.

ELECTRICAL HAZARDSELECTRICAL HAZARDS

PRECAUTIONSPRECAUTIONS

INSPECT THE POWER CORD AND PLUG INSPECT THE POWER CORD AND PLUG BEFORE EVERY USEBEFORE EVERY USE


DO NOT USE EQUIPMENT ON WHICH DO NOT USE EQUIPMENT ON WHICH LIQUIDS HAVE BEEN SPILLED.LIQUIDS HAVE BEEN SPILLED.


NEVER STACK THINGS ON OR BEHIND NEVER STACK THINGS ON OR BEHIND ELECTRICAL EQUIPMENT WHICH MIGHT ELECTRICAL EQUIPMENT WHICH MIGHT INTERFERE WITH PROPER VENTILLATION OF INTERFERE WITH PROPER VENTILLATION OF THE DEVICE.THE DEVICE.


TWO-PRONG TWO-PRONG EXTENSION CORDS EXTENSION CORDS OR ADAPTORS OR ADAPTORS SHOULD NOT BE SHOULD NOT BE USED IN THE OR.USED IN THE OR.


USE THREE-PRONG USE THREE-PRONG EXTENSION CORDS EXTENSION CORDS ONLY WHEN ONLY WHEN NECESSARYNECESSARY


DO NOT RUN OVER DO NOT RUN OVER POWER CORDS POWER CORDS WITH WHEELS OF WITH WHEELS OF EQUIPMENTEQUIPMENT


DO NOT TIGHTLY DO NOT TIGHTLY COIL OR KINK COIL OR KINK CORDS.CORDS.


ALWAYS PLUG PORTABLE ALWAYS PLUG PORTABLE EQUIPMENT INTO THE WALL OUTLET EQUIPMENT INTO THE WALL OUTLET AND TURN POWER ON PRIOR TO AND TURN POWER ON PRIOR TO MAKING ANY CONNECTION TO THE MAKING ANY CONNECTION TO THE PATIENT.PATIENT.

REMOVE ANY PATIENT CONNECTIONS REMOVE ANY PATIENT CONNECTIONS BEFORE TURNING OFF POWER OR BEFORE TURNING OFF POWER OR UNPLUGGING FROM WALL.UNPLUGGING FROM WALL.

ISOLATED SYSTEMSISOLATED SYSTEMS

ISOLATE O.R. ELECTRICAL SYSTEMS ISOLATE O.R. ELECTRICAL SYSTEMS FROM GROUNDED CIRCUITS IN THE FROM GROUNDED CIRCUITS IN THE POWER MAIN OF THE HOSPITALPOWER MAIN OF THE HOSPITAL Current flows from one isolated line to anotherCurrent flows from one isolated line to another Line isolation monitors check the degree of Line isolation monitors check the degree of

isolation by continuously measuring isolation by continuously measuring resistance and capacity between two isolated resistance and capacity between two isolated lines and groundlines and ground

ISOLATED SYSTEMSISOLATED SYSTEMS

If the current leakage If the current leakage exceeds safe levels, exceeds safe levels, an alarm soundsan alarm sounds

Unplug the last piece Unplug the last piece of equipment plugged of equipment plugged in and tag for repair in and tag for repair

ELECTROSURGERYELECTROSURGERY

Application of electrical current to Application of electrical current to coagulate or cut tissuecoagulate or cut tissue

The electrosurgical generator provides the The electrosurgical generator provides the power for electric current to travel directly power for electric current to travel directly to tissue and utilizes alternating current to tissue and utilizes alternating current (AC)(AC)

ELECTROCAUTERYELECTROCAUTERY

Term often used to mean electrosurgery Term often used to mean electrosurgery but is distinctly differentbut is distinctly different

Electrocautery utilizes direct current (DC) Electrocautery utilizes direct current (DC) via heated wire to burn tissue.via heated wire to burn tissue.

No electricity passes through patient’s No electricity passes through patient’s bodybody

HISTORY OF HISTORY OF ELECTROSURGERYELECTROSURGERY

In ancient times, In ancient times, people used hot people used hot pokers, etc. to burn pokers, etc. to burn bleeding flesh to stop bleeding flesh to stop the flow.the flow.


In 1926 Harvey In 1926 Harvey Cushing, a Cushing, a neurosurgeon and neurosurgeon and William Bovie, a William Bovie, a biophysical engineer biophysical engineer developed an developed an electrosurgical unit for electrosurgical unit for neurosurgical neurosurgical procedures.procedures.


By the early 1930’s, By the early 1930’s, the first commercial the first commercial “Bovie” units were “Bovie” units were produced and being produced and being used in operating used in operating rooms.rooms.

BENEFITS OF BENEFITS OF ELECTROSURGERYELECTROSURGERY

Reduction of intraoperative and post-operative Reduction of intraoperative and post-operative hemorrhagehemorrhage

Decrease in operating timeDecrease in operating time

Reduction of patient morbidityReduction of patient morbidity

It has become one of the most commonly used It has become one of the most commonly used surgical devices in all surgical specialtiessurgical devices in all surgical specialties

ELECTROSURGERYELECTROSURGERY

Energy produced is Energy produced is high frequency radio high frequency radio waves in excess of waves in excess of 100,000 hz100,000 hz

Produces Produces approximately 2000 approximately 2000 degrees F of heat degrees F of heat when met with when met with resistance (such as resistance (such as human tissue)human tissue)

ELECTROSURGICAL MODESELECTROSURGICAL MODES

MONOPOLAR – electrical energy flows MONOPOLAR – electrical energy flows from a generator to an active electrode from a generator to an active electrode such as Bovie (ESU) pencil and tip to the such as Bovie (ESU) pencil and tip to the patient with some result on tissue patient with some result on tissue

Then out via the inactive electrode (or Then out via the inactive electrode (or dispersive ground pad) and back to the dispersive ground pad) and back to the generatorgenerator

MONOPOLAR MODEMONOPOLAR MODE

The path of electrical energy in a The path of electrical energy in a completed ESU circuit is:completed ESU circuit is:

Wall plug > ESU generator > active electrode Wall plug > ESU generator > active electrode (pencil tip or endoscopic inst) > patient > (pencil tip or endoscopic inst) > patient > inactive electrode (ground pad) > ESU inactive electrode (ground pad) > ESU generator > wall pluggenerator > wall plug

MONOPOLAR MODESMONOPOLAR MODESMonopolar energy of the ESU can be set for pure Monopolar energy of the ESU can be set for pure cutting, pure coagulation, or a blend of cutting and cutting, pure coagulation, or a blend of cutting and coagulation.coagulation. Cutting mode – can achieve effects by using less voltage Cutting mode – can achieve effects by using less voltage

because the frequency is higherbecause the frequency is higher It vaporizes tissue but does not dissipate heat to It vaporizes tissue but does not dissipate heat to

surrounding tissue.surrounding tissue.

MONOPOLAR MODEMONOPOLAR MODECoagulation mode – uses more dissipated Coagulation mode – uses more dissipated heat to cause hemostasis of blood vessels heat to cause hemostasis of blood vessels by producing coagulum and char to seal by producing coagulum and char to seal off. off.

Causes more damage to tissues and may Causes more damage to tissues and may inhibit healing of tissues if used too muchinhibit healing of tissues if used too much

Current may be applied to hemostat Current may be applied to hemostat placed on bleeding vessel to cauterizeplaced on bleeding vessel to cauterize

Is not appropriate for large bleeding Is not appropriate for large bleeding vesselsvessels


BLENDED MODES - BLENDED MODES - voltage and frequency voltage and frequency are changed are changed

Tissue results are a Tissue results are a mix of cutting and mix of cutting and coagulationcoagulation


Endoscopic instruments may be electrified Endoscopic instruments may be electrified by attaching a cord to a metal prong on by attaching a cord to a metal prong on the instrumentthe instrument

Power is activated by foot pedalPower is activated by foot pedal

May be used for either cutting or May be used for either cutting or coagulation modescoagulation modes

The patient MUST be grounded when The patient MUST be grounded when monopolar current is usedmonopolar current is used


Capacitive coupling – unintended Capacitive coupling – unintended electrical energy delivered to non-target electrical energy delivered to non-target tissues. tissues. Occurs during laparoscopic procedures where Occurs during laparoscopic procedures where

visibility is limitedvisibility is limited Occurs as a result of insulation failure Occurs as a result of insulation failure May be prevented by shielding devicesMay be prevented by shielding devices Burns to internal organs are potentially fatalBurns to internal organs are potentially fatal

PERSONNEL HAZARDSPERSONNEL HAZARDSElectrical shock may be delivered to surgeon or Electrical shock may be delivered to surgeon or assistant due to:assistant due to: Tiny hole in latex surgical glovesTiny hole in latex surgical gloves High setting on ESU causing hole in glove and High setting on ESU causing hole in glove and

subsequent burn – called dielectric breakdownsubsequent burn – called dielectric breakdown

PERSONNEL HAZARDSPERSONNEL HAZARDS

VAPORIZED TISSUE PLUME – may VAPORIZED TISSUE PLUME – may contain hazardous ingredients such as contain hazardous ingredients such as carcinogens, bloodborne pathogens, and carcinogens, bloodborne pathogens, and viral particlesviral particles Smoke evacuators should be utilized when Smoke evacuators should be utilized when

large amounts of plume expectedlarge amounts of plume expected Special filtration masks should be worn for Special filtration masks should be worn for

laser plume caseslaser plume cases

BIPOLAR MODEBIPOLAR MODE

Electrical current passes only between the Electrical current passes only between the two prongs of the instrument and through two prongs of the instrument and through any tissue in between.any tissue in between.

Used for delicate procedures to reduce Used for delicate procedures to reduce possible nerve damage.possible nerve damage.

Patient does not need to be grounded Patient does not need to be grounded because the entire patient is not included because the entire patient is not included in the circuit, only tissue between tines of in the circuit, only tissue between tines of instrumentinstrument

GROUNDING PADGROUNDING PADAlso known as inactive electrode or Also known as inactive electrode or dispersive paddispersive pad

Must be in complete contact with patient to Must be in complete contact with patient to prevent electrical burn to patientprevent electrical burn to patient

Should be placed over a large muscle Should be placed over a large muscle mass, NEVER over bony prominence, joint mass, NEVER over bony prominence, joint with prosthetic replacement, or over metal with prosthetic replacement, or over metal implantsimplants

Should be located as close to surgical site Should be located as close to surgical site as possibleas possible

GROUNDING PADGROUNDING PADKeep as far away from pacemakers as Keep as far away from pacemakers as possiblepossibleShould be placed after final positioning to Should be placed after final positioning to prevent change in contourprevent change in contourShould be removed following case after Should be removed following case after drapes are removeddrapes are removedPad site must be inspected post-Pad site must be inspected post-operatively and result chartedoperatively and result chartedPads are available in different sizes Pads are available in different sizes appropriate to size of patient (pediatric, appropriate to size of patient (pediatric, neonatal, adult)neonatal, adult)

GROUNDING PADGROUNDING PAD

Must NEVER be cutMust NEVER be cut

Must NEVER allow prep solutions to pool Must NEVER allow prep solutions to pool under padunder pad

Ground pads sites are the major area Ground pads sites are the major area where ESU burns occurwhere ESU burns occur ECG leads provide second most common ECG leads provide second most common

burns due to alternate exit pathway of burns due to alternate exit pathway of electrical currentelectrical current

SURGICAL MODALITIES

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