Roshan Lall Gupta’s Recent Advances in Surgery (Volume 16) Puneet
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
plain X-ray 93
regions 223
reveals encapsulation 171
ultrasonography of 94
carcinomatosis, treatment of 231
compartment syndrome 56
distension 91
lymphadenopathy 179
pain 91, 172
tuberculosis 97, 165
Abemaciclib 292
techniques 38
therapies 38, 207
Acetic acid 114
Acid-fast bacilli 172
Acquired immunodeficiency syndrome 172
Actinomycin D 241
Adenocarcinoma 109, 193
risk of 116
deaminase 179
triphosphate 240
Adrenal gland
ipsilateral 204, 205
removal of 205
Adriamycin 5-fluorouracil 273
Agarose gel electrophoresis 175
Alkylating agents 220
American College of Chest Physicians 146
American College of Gastroenterology 116
American Diabetes Association 179
American Joint Committee on Cancer 202
American Society of Clinical Oncology 76, 245, 283
American Society of Colon and Rectal Surgeons 76
Americas Hepato-Pancreato-Biliary Association 30
Amikacin 182
Amyloidosis 199
Anastomotic stricture 90
Anastrozole 286, 288, 290
Anemia 199
Angioembolization 204, 210
bone of 210
role of 208
Angiogenesis 37, 249, 274, 275
Angiosarcoma 246
Anomalous pancreaticobiliary ductal junction 57
Anthracyclines 241, 273, 274
Antiangiogenic agent 245
Antibiogram 53
Anti-epidermal growth factor receptor, case of 244
drug 281
type of 292
Antiproliferative activity 274
Antireflux surgery 118
Anti-resorptive action 284
Antiretroviral therapy 182
drugs 181
treatment 169
Apoptosis 23
Appendiceal mucinous neoplasm 221
Appendiceal origin 219, 233
Appendix 8
beam coagulator 13
plasma coagulation 119, 121
pumped dye laser 20
Arimidex-nolvadex 288
Aromatic amino acids 115
Aromatization 286
hemorrhage 54
oxygen, partial pressure of 48
Arteriovenous fistula 263
Arteriovenous malformation 249, 253, 255, 256
clinical staging system for 254t
rapid progression of 254
therapy of 263
Ascariasis 90
obstruction due to 98
high density 177
malignant 230
Ascitic fluid 172
analysis 179
Aspergilloma, cases of complex 152
Aspirin 123
Atezolizumab 275
Atlanta classification 48
Atrial flutter, recurrent 22
Atrial tachycardia 22
multifocal 22
Austrian Breast and Colorectal Cancer Study Group 288
Autofluorescence 115
Autosonix system 16
Axillary lymph node 272
dissection 290
Axitinib 213
Bacillus Calmette-Guérin vaccination 173
Back pain, chronic lower 22
Bacteria, mucosal translocation of 92
Bacterial translocation 172
Balloon-diffusing fibers 122
Bannayan-Rilay-Ruvalcaba syndrome 256
Barium meal 169f
Barium studies 176b
Barrett's esophagus 108
advanced imaging for 114
clinical features 110
diagnosis 110
endoscopic image of 111f
epidemiology 108
histological diagnosis 111
management 116
natural history of disease 109
risk factors 109
role of biomarkers 113
screening guidelines for 116
therapy of 117
treatment of 120t
trials 113, 114
Vienna classification for 112t
Basal-like breast cancer 270
Bedaquiline 186
Belmont hyperthermia pump 228f
Bevacizumab 37, 38, 75, 212, 274, 275, 293
Biophysics 5
Bipolar current, effects red area 12f
Bipolar electrosurgery 11
modified 15
Birt-Hogg-Dubé syndrome 194
Bladder catheter 57
Blebectomy for pneumothorax 149
Bleomycin 210, 262
Blood brain barrier 241
Blue rubber bleb nevus syndrome 251, 259
Body and tail lesions 133
Body mass index 109, 116
Bone tumors 24
decompression, role of 96
edema 91, 94
hypoperfusion 93
ischemia ensues 91
large 93
obstruction: small and large, clinical features of 92t
small 93
Brachiocephalic vein 156
Brachytherapy 75
BRCA mutant tumors 276
Breast cancer
free interval 288
hormone therapy for 280
antiestrogen therapy in 282
emerging 293
endocrine therapy, used in 286
estrogen exposure as a risk-factor 282
evolution of 281
hormone receptor positivit 283
modalities of 284
resistance to 291
CDK 4/6 inhibitors 292
large proportion of 280
major molecular subtypes of 269t
mammographic diagnosis of 271
molecular classification of 268
progesterone receptors in 283
quadruple-negative 276
resistance protein 241
TNM staging 269
triple-negative 268276
concept of 276
imaging studies 271
immunotherapy 275
natural history of 271
prevalence of 270
prognosis of 272
radiotherapy in 275
surgery in 272
synonymous with basal-like breast cancer 270
targeted therapy in 273
treatment in 272
Breast conserving surgery 272
Breast tumors 281
British Society of Gastroenterology 111
British Thoracic Society 182
Bronchial blocker 150
Bronchogenic cyst 149
Bullectomy 149
Cabozantinib 213
Cachexia 199
Care Ontario 76
related intestinal obstruction, management of 101
specific mortality 205
specific survival 210
stem cells 244
war on 246
Candida species 53
Capacitive coupling 6
Capecitabine 74, 274, 276
plus oxaliplatin 38
arteriovenous malformation 255
lymphatic-arteriovenous malformation 255
lymphaticovenous malformation 255
malformation 249, 252, 254, 255, 256
therapy of 262
Capsule endoscopy 178
Carbohydrate antigen 199 130
Carbon dioxide, partial pressure of 46
Carboplatin 242, 273, 274
versus docetaxel 273
Carcinoembryonic antigen 28, 65, 77
Cardiac defibrillation 3
Cardiac-specific mortality 206
Cardiovascular system 284, 285
fragmentation 17
ultrasonic aspirating device 17
Cecal, management of 100
Cecostomy 104
Cecum, head of 67
Celiac plexus neurolysis 141
Cell adhesion-mediated drug resistance 243
Cell death 24
receptor-ligand-1 244
Central caseous necrosis 180
Central nervous system, metastases 268
Cerebral cavernous malformation 251
Certain familial syndromes 192
Cetuximab 37, 38, 76
multidisciplinary concept 37
Chemical photosensitizer 262
Chemoprevention 123
agents, role of 124
after initial chemotherapy 140
neoadjuvant 135, 136, 290
cancers, treatment of 246
cells 244
clones 244
Chemotherapy 36
adjuvant intraperitoneal and systemic 229
by killing chemosensitive clones 244
early postoperative intraperitoneal 229
intraoperative HIPEC plus intravenous 229
neoadjuvant intraperitoneal plus intravenous 228
pharmacokinetic properties of 239
Chest wall invasion 150
Chicken intestine 176
Cholangitis 135
incidence of 141
Cholecystectomy 57, 226
Chorioretinopathy 253
Chromoendoscopy 114
Cisplatin 241, 242, 273, 274
Cisplatinum 210, 273
Clinical Outcomes of Surgical Therapy trial 77
Clinical risk score 36
Clonal evolution 244
Clots, removal of 97
Cold spray anesthetics 24
Colectomies 226
Collagen, presence of 115
College of American Pathologists 283
Colo Rectal Endoscopic Stenting trial 73
Colon cancer
adjuvant and neoadjuvant therapy 74
approach to patients with metastatic disease 73
computed tomography of chest 64
differences between right-and left-sided 63t
disseminated to ovaries 229
epidemiology, changing trends 62
involving adjacent organs 229
low anastomotic leak rate in right 71
management of 62
ongoing research impact future practice 78
open versus laparoscopic surgery for 69
investigations 63
management 65
role for
positron emission tomography 64
radiation therapy in 75
surgery for 66
surveillance 76
use of monoclonal antibodies 76
Colon head, ascending of 67
decompression 104
lesions 171
obstruction 90
resection 74
stenting 101
Colonography 63
Colonoscopic 179
decompression 104
Colonoscopy 223
versus computed tomography colonography 63
cancer 27
investigation to detect 63
metastatic 27
screening down 62
liver metastases 64
defining resectability 30
factors influencing the treatment strategy 30
lesions 28
majority of 27
management of 27
MRI 29f
surgical management of 30
malignancy 90
surgery 98
Compensatory anti-inflammatory response syndrome 46
Confocal laser endomicroscopy 114
probe-based 115
Conglomerate mass 172
Constipation 92
Contrast-enhanced computed tomography 28, 43
Coregulators 282
Corneal burn 21
Cough 199
capacitive 9, 10f, 11
direct 9, 9f
C-reactive protein 151
Crohn's disease 90, 97, 102, 169, 178, 183
Cryoablation 119, 207
Cryotherapy 23, 24, 121
uses of 24
Crystal violet 114
Current density 4
Cyclic vomiting syndrome 47
Cyclin-dependent kinase 285, 291
Cyclophosphamide 273
Cystic masses 200
Cystitis 184
Cystoduodenostomy 50
Cystogastrostomy 50
Cytochrome P450 enzymes 241
Cytokeratin 223
Cytoreductive nephrectomy 209, 210
Cytoreductive surgery 220, 223, 225
Cytoreductive surgery and HIPEC
complications of 230
contraindications to 230
indications for the combined treatment 229
role of 231
Cytosponge: trefoil factor-3 113
procedure 73
surgery 219
Deep vein thromboembolism 66
Dehydrated alcohol 141
Demodulated currents 7
Deoxyribonucleic acid 242
damage repair 242
Depression 286
pinch 110
plication 149
Diatrizoate meglumine 94
Diatrizoate sodium 94
Diffusion weighted images 221
Dihydropyrimidine dehydrogenase 78
Dilated small bowel loops 175
Disease-free survival 288
benefit 74
Disease-specific survival 36
Distal gastrectomy 226
Distal pancreatectomy 138
pancreaticoduodenectomy 54
Diverticulitis 90
DNA crosslinking agents 276
Docetaxel 274
Double balloon enteroscopic 103, 178
Double wall sign 93
Doxorubicin 211, 225, 240, 242, 262
Drug delivery system 78
Drug-eluting beads preloaded with irinotecan 38
Drug resistance
in cancer 239
chemotherapy sensitivity 245
different mechanisms of 240
looking into future 246
mechanisms of 240f
overcoming resistance: challenging present dogmas 245
principles of 239
reaching the moon 246
tumor microenvironment 243
strains 186
tumor subpopulation 240
Drug sensitivity test 173
Ductal carcinoma in situ 285
Duodenal mobilization 100
Duodenojejunostomy 100
Duodenum, head of 67
Dysfunctional apoptosis 240, 243
Dyspepsia, symptoms of 168
Dysphagia detect 116
Dysplasia 111
high-grade 118
indefinite for 119
low-grade 112f, 118
Dyspnea 199
Early Breast Cancer Trialists’ Collaborative Group 281
Eastern Cooperative Oncology Group 139
Efavirenz 182
Elective colonic resection 72
Electrocautery 3
Electrolyte imbalance 92
Electrosurgery 2
in laparoscopic applications, use of 13
recent technological advances in 13
use of 7
device 9, 17
generator units 4
pencil works 3
Embolization technique 263
Embolotherapy 263
Emesis 91
Emphysema and lung volume reduction surgery 158
Empyema, early stage 152
Enchondroma 256
Endobronchial suction 150
Endocytosis 240
Endogenous biological substances 115
Endometrial carcinoma, risk of 284
Endopelvic fascia 66
Endoprosthesis 22
ablative therapies 119
biopsy 169
diagnosis 110
mucosal resection 122
resection 122123
retrograde pancreatography 134
submucosal dissection 122123
transgastric and transduodenal drainage 50
ultrasonography 52, 131
ultrasound- fine-needle aspiration 179
Endoscopy 178, 223
findings surveillance 120
Endosuturing 159
Endotracheal intubation, introduction of 149
Endotracheal tube 150
Endovascular treatment 263
laser ablation 260
radiofrequency ablation 260
Energy sources, different 17f
Enhanced recovery after surgery protocols 65
Enteral stents for colonic obstruction 73
Enterobacteriaceae 53
Enterococcus 53
Enterocutaneous fistula 181, 183
Enteroliths 90
Enterovesical fistula 184
Enzyme aromatase, inhibitors of 286
Epidermal growth factor receptor 37, 76, 283
Epigastric pain 110, 130
Epilepsy 255
Epipodophyllotoxins 241
Epirubicin 273
appendix cancer 233
mesenchymal transition to 243
ovarian cancer 234
Epithelioid 233
tubercles 166
variants 234
Eribulin 276
Erlotinib 140, 241, 244
Erythrocyte sedimentation rate 199
Erythropoietin 212
leiomyoma enucleation 149
premalignant lesion 24
Esophagectomies 159
Esophagectomy 117, 149
in esophageal cancer 153
Esophagus 146, 149
Estrogen receptor-mediated
membrane signaling 283
mitochondrial 283
nuclear signaling 283
Estrogen response elements 282
Estrogen synthetase 286
Ethambutol 165, 181, 182
Ethanols 263
Ethylene-vinyl-alcohol-copolymer 263
European Institute of Oncology 269
European Organisation for Research and Treatment of Cancer 37
Everolimus 214, 275
Excimer laser, uses of 21
Exemestane trial 289
Extracellular stroma 243
Extraintestinal structures, obstruction of 55
Familial leiomyomatosis 194
impaction 90
tagging, use of 64
Fecaluria 184
Fibrin degradation product 47
Fimbrial 8
Finney's strictureplasty 183
Fistulography 184
Flank mass 199
Fludeoxyglucose 131
Fluid resuscitation 95
in-situ hybridization 175
resonance energy transfer 292
Fluorescent nanoparticles 78
Fluorodeoxyglucose 29f
positron emission tomography 65
Fluorophores 115
differential amounts of 115
Fluoroquinolones 182
Folinic acid plus either irinotecan 36
Follicle stimulating hormone 286
Football sign 93
Forced vital capacity 151
Foreign material 97
Fraction of inspired oxygen 48
Fuhrman's grading 198, 214
Fulguration 5
maximum pause in 5
Fulminant hepatitis 182
Fulvestrant 290
Fundoplication partial 118
Gallstone ileus 90
Galvanic current 3
Ganglia 141
cancer, recurrent 219
emptying 66
folds, proximal margin of 110
outlet obstruction 168
Gastroduodenal artery 137
Gastroesophageal junction 108
Gastroesophageal reflux disease 108, 116
obstruction 47, 55
tract, mucosal layer of 166
tuberculosis, cases of 180
Gastrojejunostomy 100, 135
Gastroparesis 66
Gefitinib 241, 244
Gelatinous ascites 233
Gemcitabine 134, 135, 140, 210, 211, 273
monotherapy 139
Gene expression pattern 269
Germline mutations 109
Gerota's fascia 204, 205
Gland, tail of 49
Glaucoma 255
Glissonian capsule removal 226
Glomuvenous malformation 251
Glutathione S-transferase 242
Gonadotropin releasing hormone 284
Goose neck deformity 176
Gorham stout syndrome 256
Goserelin 286, 290
Granulomatous ailment, chronic 165
Granulomatous inflammation 166, 177, 180
Greater omentum 220
Ground pad failures 6
Growth factor receptor pathways 291
Harmonic scalpel 16
Hartmann's procedure 71, 100, 101
Heineke-Mikulicz technique 183
Hemangioendothelioma 250
Hemangioma 250
Hemangiopericytoma 250
Hematemesis 110
dissemination 166
spread to lungs 198
Hematoporphyrin derivative 20
left 226
right 226
Hemiparesis, form of 255
Hemodialysis 192
Hemodynamic instability 183
Hemoptysis 199
Hemorrhagic shock, acute 54
Hemostasis 6, 14
Hepatic parenchyma, sparing partial hepatectomy 32
Hepatic resection, technical aspects of 32
Hepatocellular carcinoma 24
Hepatoduodenal ligament, involvement of 226
Hepatosplenomegaly 177
Hereditary lymphedema, primary 253
Hereditary type papillary 194
internal, management of 97
obstructed 96
Holmium laser 20
Holmium:Yag laser 21
Homeobox transcription factor 223
Homogeneous collection 49
receptor positive 280, 285
replacement therapy 282
therapeutic agents and clinical usage 285t
adjuvant 287
neoadjuvant 290
Host immune components 211
Hounsfield units 200
Hour-glass stenosis 176
Human epidermal growth factor receptor 2 268, 284
Human immunodeficiency virus 165
Hyaluronate carboxymethylcellulose 98
Hydro-dissection 21
Hydrophilic nontoxic metabolite conjugates 242
Hydroxy-progesterone caproate 284
Hyperbaric oxygen therapy 97
Hypercalcemia 199
Hyperglycemia 48, 214
Hyperhidrosis 158
Hypersegmentation of barium column 176
Hypertension 192, 199
Hyperthermia 225
induced tissue changes 1
intraperitoneal chemotherapy 220, 223
rationale of 225
various techniques of 226
solution 226
Hypertrichosis-lymphedema-telangiectasia 253
Hypocalcemia 48
areas in around organ 177
lesions on portvenous phase 28
Hypofractionated 210
Hypokalemia 92
Hypophosphatemia 214
Hypoplastic deep veins 255
Iatrogenic factors 192
Ileocecal 182
region 176, 183
Ileorectal anastomosis 101
Ileostomy 71
Ileotransverse bypass is reserved 71
Imatinib resistance mutation analysis 245
Immune system 244
Immunoglobulin G4 57
Immunohistochemical staining 221, 283
Immunohistochemistry 193
Immunological factors 211
Immunomodulatory properties 211
Immunotherapy 210, 277
strategies, newer 211
Indigo carmine 114
Indocyanine green 159
Infected pancreatic necrosis 52
Inflammation, acute 97
Inflammatory bowel disease 90, 102, 179
Infraclavicular nodes 272
Infrared: near, advantages of 78
Infundibulopelvic 8
Iniparib 274, 275
Insulation failure 7
Insulin-like growth factor 1 283
Intensive care unit 47, 151
Interaortocaval lymph nodes 198
Interferon-gamma release assay 173
Interferons 211
Intergroup Exemestane Study 288
Interleukin-2 211
International Society for the Study of Vascular Anomalies classification 250t
International Society of Urological Pathology 198
International Study Group of Pancreatic Surgery 135
International Union for Cancer Control 202
Interstitial edematous pancreatitis 43
metaplasia 121
obstruction 89, 181
accuracy of diagnosis of 93
causes of 90t
choice of surgical procedures 101
classification of 89
clinical manifestations 91
diagnosis 92
large 92
management of 89, 95
pathophysiology 91
role of laparoscopy in management of 102
signs of 92
small 92
tuberculosis 175
ulcers 181
non-viable 97
viable 97
Intra-abdominal adhesions
common causes of 97
grades of 90t
Intra-abdominal free fluid 178
Intracranial components 255
Intractable diarrhea 138
Intramucosal cancer 108, 112, 116
Intraperitoneal chemotherapy
regimens, types of 228
role of 220
use of 220
Intraperitoneal viscera 219
Intratumoral signal intensity 272
Intussusception 90
Invasive ductal carcinoma 285
Inverted umbrella sign 176
Irinotecan 36
Ironoxide nanocrystal contrast agent in MRI 78
Ischemia 23, 24
presence of 92
Isolated and grounded generator system 4
Isoniazid 165, 181, 182
Italian Tamoxifen Anastrozole 88
Ixabepilone 273
Japanese Society for Cancer of the Colon and Rectum 67
Jaundice 199
obstructive 134
Jejunal obstruction 55
Kinase receptor inhibitor 213
Kirsten rat sarcoma wild-type 38
Klebsiella 53
Klippel-Trenaunay syndrome 255, 256, 259
K-ras 73
Krukenberg tumor 230
Lactate dehydrogenase 93, 200
necrosectomy 54
procedures 15
surgery 6, 9, 24
oncological safety of 70, 79
use in 5
versus open colon cancer surgery 77
versus robotic surgery 70
Large intestine 10
Laser 18
beam, methods of release of 19
biophysical, principles of 19
generation, method of 18
properties of commonly used 9t
therapy 262
tissue interaction 20
unique properties of 18
Laxatives overuse 103
Letrozole 286, 288, 290
Leucovorin 36, 74
Leukemia 241
Leuprolide 286
instruments 15
vessel sealing system 15
Light Amplification through Stimulated Emission of Radiation 18
Liposomal 273
Liquefactive necrosis 166
abscess 184
first approach, systemic chemotherapy 32
function test 182
metastases 29f
approach to patient with synchronous 31
oncosurgery management of 32
synchronous versus metachronous 27
synchronously detected 34fc
unresectable, treatment options for 38
parenchyma 38
resection 38
Lobectomy 146, 149, 157, 159
Lobular carcinomas 291
Locoregional therapy 38
Loop colostomy 72
Low-molecular-weight heparins 141, 259
Luminal tumors 273
Lung 149
and breast cancers 241
and diaphragm 146
early stage 149
resection for 153
video-assisted thoracic surgery 153
volume reduction surgery 149
Lymph node 150
dissection 153, 209
involvement 178
tuberculosis 177
Lymphadenopathy 177
Lymphatic malformation 249, 252, 255, 256, 262
classification of 253b
therapy of 261
Lymphaticovenous malformation 255
Lymphedema 253
choanal atresia 253
distichiasis 253
Lympho-adipose tissue 67, 69
Lymphocyte 151t
Lymphoma 241
Lymphovascular invasion 77, 276
Macrocephaly 256
Macrocystic, treatment of 262
Maffucci syndrome 256
Magnetic resonance angiography 253
Malignancies, primary 231
Malignancy 178
spreads 223
Malignant peritoneal mesothelioma 233
Malnourished patients 99
Mantoux test 173
Marshall scoring system, modified 47, 48t
Maryland dissector 9f
Mediastinal biopsies 158
Mediastinal space for thymic surgery 156
Mediastinal tumors, posterior 149, 159
Mediastinum 146, 149
Megestrol acetate 284
Melted extracellular water 1
Memorial Sloan Kettering Cancer Center 36
Menopausal symptoms 286
Mental retardation syndrome 253
Mesenchymal components 249
Mesenteric artery syndrome, superior 90, 99, 130, 132
precipitating factors for 99
radiological criteria for diagnosing 99
surgical procedures 100
Mesenteric ischemia 91
Mesenteric lymph nodes 166
Mesenteric tubercles, multiple 180
Mesenteric vein, superior 67, 130, 137
Mesocolic excision
complete 68f
main component of 67
Mesorectal excision 66
Metabolic complications 48
Metachronous cancer, detect 76
Metachronous lesions 74
cannula system 12
stent, self-expanding 71, 135
Metaplastic mucosa causes 110
Metastasectomy 204
Metastatic breast cancer 280, 285
hormone therapy for 289
Metastatic colorectal tumor 76
Metastatic lesions 199
Methylation 242
Methylene blue 114
Microarray-based technology 268
Microsatellite instability 74
Microsomal enzymes metabolize 241
Microtubule stabilizer 273
Microvascular invasion 214
Microwave ablation 22
Minimal access retroperitoneal pancreatic necrosectomy 54
Minimally invasive technique 183
Minimally invasive thoracic surgery 146159
benefits of 151, 151b
benign indications for 152
contraindications 150
future prospects in 156
indications for 149
indications for diagnostic 149
indications for therapeutic 149
oncological aspect of 153, 155
principles of 150
technological advances in 158
thymoma for 155
Mitochondria 21
Mitomycin C 225, 228
genetics 193
methods 173
subtype 269
antibodies 212
antibody bevacizumab 76
Monopolar electrosurgery 11
Mucinous tumors 226
Mucosal integrity, loss of 91
Multidrug resistance 239
emergence of 165
Muscle strength 66
detected 245
in the signaling pathway 76
of exon 2 76
Myalgias 286
Myasthenia gravis 155
thymectomy for 149
Mycobacteria detection, culture and drug sensitivity 174t
Mycobacterial culture 173
Mycobacterium tuberculosis 172
Myeloid leukemia, chronic 244
Myeloma cell 243
Myeloma upregulate 241
Nab-paclitaxel 134, 274
Nanotechnology 78
Nasogastric tube 91
National Comprehensive Cancer Network 28, 64, 76, 129, 146
National Surgical Adjuvant Breast and Bowel Project 281
Necrotic collection 52f
acute 50
Neodymium-doped:yttrium aluminum garnet 260
Neostigmine 104
kidney cancers prostate cancer 24
surgery versus radical nephrectomy 206
Neuroblastoma RAS 73
Nicotinamide adenine dinucleotide hydrate 115
Nitroimidazole-oxazine PA-824 185, 186
Nonhomologous end joining pathway 242
Nonmetastatic hepatic dysfunction 199
Nonne-Milroy syndrome 253
Non-nucleoside reverse transcriptase inhibitor 182
Nonsteroidal anti-inflammatory drugs 110
Nuclear pleomorphism 268
Nuclear scintigraphy 200, 202
Nucleic acid amplification tests 173
Nucleotide excision repair 242
pathway 242
Obesity 192
Obstructed colonic cancer, management of 70
Odynophagia 110
Olaparib 274, 275
Oligometastatic disease 210
presence of 138
Oncotype-Dx 289
Ophthalmologic lasers, hallmark of 18
Oral contraceptive pills 282
Organ dysfunction syndrome, multiple 46, 47
risk of 46
Organ failure
assessment, sequential 47
multiple 44
persistent 46, 47
transient 46, 47
Orthopedic surgery 22
Osteolytic metastatic bone 199
Osteoporosis 286
cancer, recurrent 230
function suppression 287, 288
ligaments 8
tumors 101
Oxaliplatin 36, 75, 228, 273
Paclitaxel 274, 275
Pain 199
Pain and infection 252
Palbociclib 292
care 140
interventions 204
measures, specific 140
divisum interfering 57
head of 49, 67
protocol 130
abscess 47, 52
ascites 56
cancer, advanced 129
cancer, borderline resectable 129141
definitions 131
evaluation and workup 130
principles of management 134
prognosis 142
cancer, locally advanced 132f, 138, 139
cancer, surgical techniques for 138
fistula 138
necrosis 51f
parenchymal necrosis, presence of 44
pleural effusion 56
pseudocyst 49, 50f
resection 54
sphincterotomy 57
stump 138
tests 57
Pancreaticoduodenal arteries 54
Pancreaticoduodenectomy 138, 172
specimen 137f
Pancreatitis, acute 43
classification of 45fc
complications of 43, 46, 47t
phases of 45
recurrent 57
causes of 57
severity, classification of 44
severity, grades of 44t
systemic complications of 47
types of 43
Pancreatitis edematous 44
Pancreatitis, mild acute 44
Pancreatitis, moderately severe acute 44
Pancreatitis necrotizing 43
Pancreatitis, severe acute 44
Pancreatoduodenectomy 138
Panitumumab 37, 38, 76
Para-aminosalicylic acid 165
Paracolic gutters, left and right 226
phenomenon 199
syndromes 199
Parathyroid hormone-like peptides 199
dissection 21
organs 21
Parkes Weber syndrome 256
Partial nephrectomy 206, 207
Paustian's criteria 181
Pazopanib 213
Peak hepatic enhancement 130
Pegylated variety 273
Pembrolizumab 275
Peptide growth factor mediated 283
catheter drainage 53
microwave ablation 23
sclerotherapy 264
Perianal fistulae 181, 184
Pericardium 233
Periduodenal lymph nodes 168
tissues 204
fat 205
arteries 130
collection 55f
fluid collection, acute 48, 49
necrotic 51
Perirenal hematomas 199
adhesion 89
carcinomatosis 219
assessment of 224f
cases with mucinous 223
colorectal cancer 231
detection 221, 222t
diagnosis 220
gastric cancer 232
management of 223
ovarian cancer of 234
prevent of 232
staging, disease burden 223
cavity 57, 99
epithelial implants, multifocal 233
malignant mesothelioma, treatment choice for 234
mesothelioma 229, 233, 234
metastasis 74, 220
mucinous carcinomatosis 233
pseudomyxoma 229
sarcomatosis 230
Peritoneum 166, 233
Peritonitis 97
Peritumoral inflammation 72
Phenothiazines 103
Phosphoinositide 3-kinase inhibitors 293
Photoablative 19
Photochemical 20
Photodynamic therapy 119, 122, 262
Photokeratitis 21
Photothermal 20
Picibanil 262
Pinocytosis 240
Platelet-derived growth factor 212, 274
Platinum-based primary intraperitoneal chemotherapy 234
Pleura 149
serosal layer of 233
biopsy 149
effusion 56, 158
Pleurodesis 149
Pneumaturia 184
Pneumonectomy 149
Pneumonitis 214
Poly (ADP-ribose) polymerase inhibitors 274
Poly-adenosine diphosphate 243
Polycythemia 199
account of 199
Polymerase chain reaction 175, 179
Porfimer sodium 122
Porphyrins 115
Portal fashion 147
Portal vein 130, 132, 133, 137
Portal venous phase 28, 130
Port-wine stains 254
Positron-emission tomography 77, 131, 222
role of 202
obesity, case of 282
women 288
Potassium 183
titanyl phosphate lasers 262
Potent multikinase inhibitor 274
Pouch of Douglas 226
Power cutting 17
Premenopausal women 288
Procarbazine 242
Progestins 284
like medroxy-progesterone acetate 284
Progressive disease, supportive care for 140
Prostaglandins 199
Prosurvival signals, external 240
Protective stoma, use of 71
calorie malnutrition 48
correlates 292
denaturation 15
Proteus syndrome 256, 261
Proton pump inhibitors, use of 109
Pseudoaneurysm-associated bleeding 54
Pseudocapsule 193
Pseudocysts 49, 50
contents of 52
pancreatic 54
reports of 56
Pseudomyxoma peritonei 219, 227f, 233
Pseudo-obstruction 103
causes of 103
old age 90
aspergilloma 152
biopsies 158
fibrosis 262
nodules, resection of 158
Pulse mode 18
Pulsed current 3
Pure coagulation current 6
Purified protein derivative 173
Purse-string stenosis 176
Purtscher's retinopathy resulting 57
Purulent form 172
Pyogenic granuloma 250
Pyrazinamide 181, 182
Pyrexia 199
in neoadjuvant setting 136
proctitis 90
therapy, intensity modulated 75
Radical nephrectomy 204, 206, 206f, 210
part of 205
procedure 205
Radical total pancreaticosplenectomy 137f
Radioembolization 28
ablation 22, 38, 119, 207, 208
current 2
output 14
Radioisotope renogram 202
Radiotherapy 139
Radiotherapy, conventional 210
versus stereotactic 136
Ranson's criteria 43
Rapamycin 275
mammalian target of 213, 274, 275, 291
mechanistic target of 259
Rectal cancer 29f
Regional lymphadenopathy 200
cell carcinoma 190, 206, 209f
bilateral 201f
clinical features 198
computed tomography 200
imaging 200
investigations 202
laboratory findings 200
magnetic resonance imaging 201
physical examination 199
epidemiology 191
etiology 191
familial subtypes 194t
grading systems 198t
histological, subtypes of 196t
immunotherapy 211
management 204
pathology 193
pulmonary metastases in 203f
recent advances in 190
role of genetic factors 192
staging 202
systemic therapy for advanced/metastatic 210
targeted therapies 212
TNM staging 203
treatment of
advanced 208, 209
localized 205
disease, end-stage 192
failure, acute 47
parenchyma 193
tumors 200
vein 204
Retinal damage 21
Retinoblastoma 24
Retrograde transvenous embolization technique 263
hematoma 54, 103
lymph nodes 172
Retroperitoneoscopic approaches 207
Retroperitoneum 54, 57
Rhabdoid morphology 198
Ribociclib's 292
Ribose polymerase 243
Rifampicin 165, 181, 182
resistance 175
Rigler's sign 93
Robotic thoracic surgery 159
Roux-en-Y cystojejunostomy 50
components 211
elements 214
variants 210
Schobinger classification 263
Sclerotherapy 259, 262
principle of 260
Segmentectomy 149, 157, 159
Selective ER
degraders 284
modulators 284
Semiclosed technique 226
Sentinel lymph node 290
Seprafilm 98
Serosal surfaces 219
Sertraline 246
Serum amino transferases 130
Servelle-Martorell syndrome 256
Short bowel syndrome 183
Sigmoid colectomy, specimen of 32
Sigmoid lesion, synchronous resection of 33
Sigmoid volvulus 100
Sigmoidopexy 100
Single strand DNA breast 274
Sinusoidal fashion 3
Sirolimus 261
role of 259
Skeletal pain 199
discoloration 252
malignancy 21
Small bowel
disease, extent of 225
feces sign 95
obstruction 89, 90
tuberculosis 182
Smart electrode technology 14
Smoking, cessation of 192
Sodium 183
Soft tissue densities 177
Sorafenib 212, 274, 275
Sparking and arcing 9
deformity 99
metastatic sites 210
trauma 99
Spindle cell hemangioma 256
Splenectomy 55, 138, 226
artery 54
artery embolization 55
vein thrombosis 54, 55
Spontaneous pneumothorax 158
Squamocolumnar junction 110
Staphylococcus aureus 53
Statins 123
Stauffer's syndrome 199
Stem cell transplantation 211
body radiation therapy 38, 74, 140, 210
radiosurgery 210
Sternotomy, median 156
Steroid hormone 17-beta-estradiol 281
Stierlin sign 176
Stoma related complications 76
cells 243
elements 282
Sturge-Weber syndrome 254, 256
cancer 112
lymphoid tissue 166
Subtotal colectomy
limitations with 72
versus segmental colectomy 72
Succinate dehydrogenase 194
Suck cut technique 122
Sulfotransferases 242
Sunitinib 213, 241, 274, 275
lymphadenopathy 200
tachycardia 22
anterior mediastinal masses for 149
locally advanced pancreatic cancer for 140
sexual problems, after 76
glove injury 6
practice, energy sources in 1
technique, good 97
Systemic chemotherapy 38
Systemic inflammatory response syndrome 45, 46b, 47
Systemic platinum-taxanes chemotherapy 234
Talc pleurodesis 158
Tamoxifen 281, 286, 287, 288, 289, 290, 292
Taxane-anthracycline combination 277
Taxanes 273
Temozolamide 242, 274
Temsirolimus 214
Testicular cancer 192
injury 8
tissue effects 1
Thioridazine 246
Thoracolaparoscopic esophagectomy 153
instruments 148
pericardial window 149
surgery 147
and video-assisted thoracic surgery, difference 147
equipment for 148
equipment required for 148
multiportal 157
ports for 147f
sympathectomy for hyperhidrosis 149
thymectomy 155
group 154
procedures 151
Thrombocytopenia 214
Thromboembolism 259
Thrombophlebitis, recurrent 255
Thymectomy 159
for thymoma 153
in myasthenic patients 158
Thymic horns 156
Thymidine phosphorylase 78, 242
Thymoma 149
early stage 156
changes, temperature determined 2
injury 7
distal site 8f
during adhesionolysis 8f
management system 14
Tobacco consumption 192
Toldt's fascia, lifting of 68f
Topoisomerase II inhibitors 242
Topotecan 274
Total pancreatectomy 138
Transabdominal ultrasonography 43, 130
Transarterial chemoembolization 38
Transcriptase-polymerase chain reaction 283
Transmembrane domain exists 241
Transmembrane proteins 282
Transoral endoscopy 110
Trastuzumab monoclonal antibody therapy 272
Trefoil factor-3 113
Tricyclic antidepressants 103
Trocar cannula units 148
Tubercular ascitis 179
Tuberculin test 173
Tuberculosis 102, 165
abdominal 97, 165185
clinical presentation of 167t
criteria for diagnosis of 181
from Crohn's disease 170t
histopathology in 180
laboratory diagnosis 172
management of 181
pathophysiology of 166
role of
diagnostic laparoscopy 180
surgery 182
sites involvement of 166
colorectal 170
current diagnostic methods for 174t
esophageal 168
extrapulmonary 175
risk of 166
gastroduodenal 168, 182
in Asia and Africa 90
jejunal and ileocecal 168
lymph node 172
new modalities in management of 185t
peritoneal 171
solid organs of 172, 177
Tuberous sclerosis 192
Tubule formation 268
Tufted angioma 250
borderline resectable 132, 133
cells 225
with sarcomatoid 198
central 38
derived 1,25-dihydroxycholecalciferol 199
detecting synchronous 65
extends 204
giant cells 198
heterogeneity 240, 244
locally advanced 138
marker 130, 221
microenvironment 244
non-metastatic 131
polyps 65
primary 31, 32
resection of 22
rupture primary resection 230
small 65
thrombus 198
unresectable 131
venous thrombus 200
Tunica vaginalis testi 233
Tyrosine kinase 275, 277
Tyrosine kinase inhibitor 213, 244, 274
UK Special Interest Group in Gastrointestinal and Abdominal Radiology 63
Ulcerohypertrophic variety 169
Ultracision, high power system 16
Ultracold liquid causes 23
cutting 16
dissectors 15
energy 15
Ultrasound, physics of 15
Ultrasurgical hook 16
Ureteral obstruction 199
Ureters 55
Urethral sling, mid 37
Uridine 5’-diphospho glucuronosyltransferases 242
US Food and Drug Administration 292
Uterosacral 8
Vagal-sparing esophagectomy 119
Vaginal prolapse repair 37
Valvulae conniventes 93
Vapor pulse coagulation 14
Vascular endothelial growth factor 76, 273
development of 212
pathway antagonists 212
Vascular malformation 249, 250, 251f, 264
associated with other anomalies 256b
chest wall involvement in 258f
classification of 250, 251b
combined therapy 255, 255b
diagnosis tool 256, 257
extensive involvement of trunk 251f
major vessels of 255
therapy of fast-flow 263
treatment 258
endovenous intervention 260
laser excision 260
medical management 259
sclerotherapy 259
surgical excision 260
Vascular organ 172
Vascular tumor 249, 250
Vasculogenesis 249
Veliparib 274, 275
Vena cava, inferior 55, 198, 199, 202, 209
Vena cavography, inferior 202
malformation 249, 250, 255, 256
elbow region of 261
therapy of 258
phase contrast-enhanced CT 28f
thromboembolism 141
tumor thrombus management of 208
Ventricular arrhythmias, types of 22
fistula therapy 184
retroperitoneal debridement 54
thoracic surgery 146, 148
augmented reality in 159
instruments 148f
limitations of 151
ports 148f
three-dimensional 158
two-dimensional 158
uniportal 156
versus open thoracotomy, benefits of 150
Vienna classification 111
Vinblastine 210, 240
Vinca alkaloids 241
Vinorelbine 276
Virgin abdomen 96
Visceral organ tuberculosis 184
Voltage waveform 12
Volumetric laser endomicroscopy 115
Volvulus 90
Vomiting 91
von Hippel-Lindau disease 192194, 212
Walled-off necrosis 52
Water jet dissection, high-velocity 21
Whirl sign 95
Wilms tumor 191, 192
World Health Organization 155, 165, 193
Wound protector 148f
Xpert M. tuberculosis 175
microspheres 75
selective internal radiotherapy 38
Chapter Notes

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Energy Sources in Surgical PracticeChapter 1

Rajeev Sinha
The present day surgeon has a number of energy sources at his disposal, to help him to cut and coagulate tissues. These energy sources include electrical, laser, ultrasonic, and mechanical. Each of these has unique properties that determine its effectiveness and limitations when used during any kind of surgery, including minimally invasive surgery. The surgeon must realize that learning the use of a specific energy source, does not in itself practically lessen the chance of a complication. A complete understanding of the equipment, physics of the energy source, its potential hazards and limitations is essential, if energy source-related complications are to be reduced.
Hyperthermia-induced tissue changes, start at, as early as 44°C in the form of tissue necrosis. Between 50°C and 80°C protein coagulation and collagen is converted to glucose. Between 80°C and 100°C, total desiccation of tissue occurs, and beyond 100°C, tissue is vaporized. With fulguration, when the temperature climbs to 200°C and above, carbonization starts and a visible black eschar can be seen (Fig. 1). The various energy sources utilized clinically, achieve varying degrees of hyperthermia. The ultrasonic wave achieves 80°C, the laser works at 200°C, and electrosurgery can achieve temperatures as high as 400°C. The final temperature acheived, however, also depends on the time that the energy source is applied to the tissue.
Hypothermia to −40°C and below, results in tissue freezing and in the postthaw period, there is vascular endothelial damage leading to thrombosis and cell membrane dysfunction. With temperature decreasing to −195°C below zero, there is intracellular and extracellular ice formation, leading to cell dehydration and shrinkage. With thawing, the melted extracellular water rushes inside the cell and the cell bursts.2
zoom view
Fig. 1: Temperature determined tissue changes.
  • Electrosurgery uses an alternating radiofrequency current in the frequency range of 500,000 to 2 million Hz per second. The rapid reversal of this very high frequency alternating current means that ion positions across cellular membranes do not change. As a result, neuromuscular 3membranes do not depolarize, and there is no danger of muscle contraction or cardiac defibrillation at these high frequencies. On the other hand, household current, with its low frequency of 60 Hz can produce ventricular fibrillation and gives the typical shock.1,2
  • The terms electrocautery and electrosurgery are often used interchangeably in modern surgical practice. However, these terms define two distinctly different electrical applications.3,4 Electrocautery is the use of electricity to heat a metallic object which then transfers the heat to the tissue helping to coagulate or burn, but, there is no current flow through the object being cauterized. In electrosurgery, the electrical current flows through the tissue and heats the tissue by the excitation of cellular ions.5,6
  • There are 3 types of electrical currents in clinical usage:
    1. Direct current, which is unidirectional, is also known as galvanic current and is used in acupuncture and endothermy but not for electrosurgery.
    2. AC or alternating current where the flow changes in a sinusoidal fashion and is used in electrosurgery.
    3. Pulsed current where a high amount of electrical energy is discharged in a very short time. It is used for electromyography and nerve stimulation.
  • Current flowing through the body takes the path of least resistance which in the human body means tissues with maximal water or in other words, the electrical resistance is in inverse proportion to water content of tissues. Thus blood is most conductive followed by nerve, muscle, adipose tissue and finally, least conductive is the bone. The path of the current in body tissues is not always a straight one. As soon as the current passes through a tissue it dries or it desiccates it, thus increasing its resistance and making it nonconductive. The current then takes the path through adjacent tissues which are still hydrated and thus have lesser resistance. Hence, the flow pattern of current through live tissue can never be predicted. Also this changing resistance of body tissues during the current flow requires that electrosurgical generators must deliver current at increasing voltages that should match the expected increase in tissue resistance of the human body, otherwise, current flow can be too low to produce the desired effect or too great, resulting in injury.
  • The current density is an important variable determining the biological effect of the current and can be defined as amperes/area or amp/cm2. This explains why the pinpoint tip of an electrosurgical pencil works more effectively than a spatula. The less the area of contact, the more the density of the current at the point of contact and thus greater would be the effect (Fig. 2). Current flowing through the tissue raises the temperature of the tissue and generates heat. The amount of heat thus released is directly proportional to the resistance of the tissues.4
    zoom view
    Fig. 2: Current density. Electrode 1 with a smaller surface area, generates current density more than under electrode 2, similarly the area of the ground pad, would determine the current density at its site of attachment. Larger surface areas for the ground pad are obviously better.
    zoom view
    Fig. 3: Isolated and grounded generator system. In the grounded generator, the current returns to the earth while in the isolated generator, the current goes back into the electrosurgical unit. All present day ESUs are isolated types.
  • The electrical current in electrosurgery can be delivered through two kinds of circuits. In the unipolar circuit, the ground pad (which is incorrectly called earth plate) takes the current back to the machine after traveling through the body.3,7 Thus it should be the aim to minimize the distance between the operating electrode and the ground pad. In the bipolar circuit, because both the positive and negative electrodes are near to each other, the current flow inside the body is minimal and is thus less damaging.
  • Electrosurgical generator units (ESU) are essentially of two types: grounded and isolated (Fig. 3). The newer isolated generators eliminate the possibility of an alternate site burn by requiring the current to return to the generator.5,8 In the early grounded generators the current returned to earth via any contact point and thus caused inadvertent alternate site burns.
  • Both the unipolar and bipolar circuits can further be modified as open and closed circuit. Open circuit is typically formed when the electrode does not make contact with the tissues or the tissue in contact with the electrode is already desiccated. In the circuit the resistance increases and 5generator increases the voltage to close the circuit and the waveform also becomes erratic. The current in closed circuit is safe and delivers lesser voltage.
The electrosurgical effect on the tissue results in three definable effects:9,10
  1. Cutting
  2. Coagulation and/or fulguration
  3. Desiccation.
  1. Cutting: True electrosurgical cutting is a noncontact activity in which the electrosurgical instrument must be a short distance from the tissue to be cut. If there is contact, desiccation leading to mechanical cutting rather than pure-cutting ensues. True-cutting requires the generation of sparks between the electrode and the tissue, which generates extreme heat which leads to cell explosion.
  2. Fulguration: In this mode also, there is a no contact between the electrosurgical delivery device and the tissue. In contrast to cutting, fulguration requires short bursts of high voltage only 10% of the time to produce sparks but a low power to produce coagulation. Coagulation and fulguration thus utilize higher voltage than cutting but the pause between current flows is more (maximum pause in fulguration). Both cause coagulative necrosis of tissues and fluid.
  3. Desiccation: Is the process by which the tissue is heated and the water in the cell boils to steam, resulting in a drying out of the cell. Desiccation can be achieved with either the cutting or the coagulation current by contact of the electrosurgical device with the tissue because no sparks are generated. Therefore, desiccation is a low power form of coagulation without sparking, and it is the most common mode used by the surgeon.
  • The blend current: The pure-cutting current will cut the tissue but will provide poor hemostasis. The coagulation current will provide excellent coagulation but minimal cutting. The blend current is an intermediate current between the cutting and the coagulation current, as one might expect. In actuality, it is a cutting current–the duty cycle or time that the current is actually lowing during activation of the electrosurgical delivery device is decreased from 100% of the time to 80–50% (Fig. 4).11,12 It is important to note that setting the generator to blend mode does nothing to alter the coagulation current that is provided. Only the cutting current is altered so that the duty cycle is reduced to provide more hemostasis.
  • Use in laparoscopic surgery: It was initially believed that the use of electrosurgery in laparoscopic surgery would have unique problems. The low heat capacity of the insufflating gas would result in instruments not 6cooling as rapidly as in the open environment. In addition the high-water content of the insufflated gas would increase the conductive capacity of the medium. But evidence does not substantiate these beliefs. However, laparoscopic application of electrosurgery has other problems, giving rise to unique complications.3,13
Injudicious use of the ESU in open and laparoscopic surgery can be associated with:
  • Grounding failures
  • Alternate site injuries
  • Demodulated currents
  • Insulation failure
  • Tissue injury at a distal site
  • Sparking
  • Direct coupling
  • Capacitive coupling
  • Surgical glove injury
  • Explosion.
Ground pad failures: The large surface area of contact of the return electrode with the body and prevents injury by dispersing the current over a larger surface area. Lack of uniform contact, however, can result in significant current concentration and damage, and any conductive low resistance object can then serve as the alternate conduit.
zoom view
Fig. 4: Difference between pure cut and pure coagulation current. Pure cut is a low voltage continuous current, while a coagulation current is of very high voltage in very short bursts. Blend mode—only the cutting current is altered so that the duty cycle is reduced (i.e. time off becomes more than on) to provide more hemostasis.
Exit of current at these alternate sites can produce injury because of the high current density.
The application of the ground pad to a body surface which is uneven results in inadequate contact and causes tissue injury. Thus the pad is best not kept under the scapulas, heels or other bony structures such as the skull. It is always safe to keep it under the buttocks or thighs or the calf muscles.
Demodulated currents: Modern generators have filters that remove demodulated currents so that only electrical current of 250–2,000 kHz is delivered. Demodulated currents occur most commonly when an electrosurgical instrument is activated off metal and then touched to the metal, such as the common practice of “buzzing a hemostat.” Demodulated currents produce neuromuscular activity that is usually of no significance unless directly coupled to the heart through a catheter or during a cardiothoracic surgical procedure. Another example of demodulated current is muscle fasciculation at the site of application during the use of electrosurgery.
Insulation failure: Insulation failure is thought to be the most common reason for electrosurgical injury during laparoscopic procedures and more commonly seen with high voltage coagulation currents. The key factor that determines the magnitude of injury from insulation failure resides in the size of the break in the insulation.5,14 Paradoxically, the smaller the break, the more the chances of it being missed and greater the likelihood of injury on contact with tissue.5,15
This is related to the concept of power density. Protection against insulation failure is provided by the active electrode monitoring system, available in many machines and which switches the current off, if there is an insulation failure.5,16
Tissue injury: Current passing through structures of small cross-sectional area may have current concentrated there, with resultant unintentional thermal injury. For example, if the testicle and cord are skeletonized and mobilized from the scrotum, application of energy to the testicle can result in damage to the cord, because the current must return to the indifferent electrode (ground pad) through the small diameter cord before it is dissipated in the body through numerous pathways. Another example is of cutting an adhesive band from the gallbladder to the duodenum with electrosurgery. If the adhesion is wider near the gallbladder than on the duodenum, the current density will be greater on the duodenum injuring the duodenum (Fig. 5).
Another inadvertent method of tissue injury may occur as follows. Reapplication of current near anal ready desiccated or fulgurated tissue may create an unwanted exit route through a small contact area, which builds up a high current density. The typical example is during electrosurgical distal tubal cauterization. Initial cauterization of the tube near the isthmus produces an electrical nonconductive tissue.8
zoom view
Fig. 5: Tissue injury during adhesionolysis. The attachment of the adhesion has a narrower duodenal attachment as compared to the gallbladder end; hence there is greater current density at the duodenal end of the adhesion. This translates into greater chances of duodenal injury.
zoom view
Fig. 6: Tissue injury at distal site. Because the first application 1 desiccates the tissue and makes it nonconductive, thus the second cauterization site denoted as 2 can only disseminate current through the tip of the appendix or the terminal end of the tubes. This would damage the adjacent structure to these sites and would present as delayed cautery burns and if the current passes to an intestinal segment in the vicinity, then usually perforation results. So after cauterization at site 1 further cauterization should not be done at site 2.
If further application is done toward the uterine side, the current exits through the uterus and out of the body. But if the current is reapplied towards the tubal side, the current can only flow out toward the ground plate through the fimbrial end and if the fimbrial end is in contact with a bowel loop it sets up a thermal injury (Fig. 6).
The tissue injury can also occur with other freely mobile or small area structures near to vital structures, such as infundibulopelvic, uterosacral, ovarian ligaments and the appendix.
Direct tissue injury is easy to recognize and repair. Indirect gastrointestinal tract (GIT) injuries are usually missed at the time when they occur only to 9manifest 72 hours later when coagulative necrosis is complete. Thus the clinical presentation is always delayed and the patient then presents with peritonitis.
  • Sparking and arcing: Jumping of sparks from the electrode to tissues is the mechanism for fulguration and true electrosurgical cutting. However, it can also occur in an unintended fashion such that injury results, especially in laparoscopic surgery. Current can jump from any place on the uninsulated end of the electrode or an area of insulation break and not necessarily only from the tip. In addition, build up of eschar, or desiccated tissue sticking on the electrosurgical instrument may promote arcing from the shaft instead of the tip of the electrode leading to sparking to a secondary site. However fortunately, sparking with monopolar electric current is small because, under normal operating conditions at 30–35 W, 50% of the time, the spark jumps only 2–3 mm, and this is not enough to allow significant air or CO2 gaps to bebridged. However, the tip of the laparoscopic instrument should always be kept clean.
  • Direct coupling: Direct coupling occurs when an electrosurgical device is in contact with a conductive instrument which then conducts electricity.9,17 Direct coupling can be reduced by using only insulated instruments and careful attention to avoid contact with any metallic object in the operative field and activating the electrosurgical electrode only inside the visual field and never near another metal object such as a clip, staple, laparoscope, or metal instrument (Fig. 7).
  • Capacitive coupling: Capacitance is stored electrical charge that occurs between two conductors which are separated by an insulator (Fig. 8)3,18.
    zoom view
    Fig. 7: Direct coupling. Accidental direct contact between the cautery connected Maryland dissector and 2nd instrument.
    zoom view
    Fig. 8: Capacitive coupling. Current generated in the outer metal trocar sheath, containing the cautery connected instrument, in accidental contact with the large intestine causes bowel injury.
    The capacitively coupled current wants to complete the circuit by finding a pathway to the patient's return electrode. The charge is stored in the capacitor until either the generator is deactivated or a pathway to complete the circuit is achieved. Capacitive coupling is greatest in the coagulation mode when there is no load on the circuit (open circuit). Capacitive coupling is considerably greater through a 5 mm cannula than through an 11 mm cannula and greater through a longer cannula. Every object in the room, the surgeon, the patient, the operating table, all have a small but finite capacitance to earth. In context to laparoscopic application it must be remembered that compound cannulas (metal with plastic sheath) should never be used. Because when capacitative current is set up in a metal cannula it must logically exit through the abdominal wall but if the plastic sheath is in place it separates the cannula from the abdominal wall and the current can only exit when the cannula tip comes in contact with any intra-abdominal structure causing unrecognized injury. Hence, the cannulas should either be only metal or only plastic, where no capacitive current is built up. Another example of capacitance can be seen with excessive length of the cautery cord lying on the table and the surgeons hand or instrument comes in contact leading to minor shock to the surgeon (Fig. 9).
A large number of the above complications can be reduced by using the electroshield system which shuts off the generator in the event of an insulation failure, or if capacitative coupled current has been generated.11
zoom view
Fig. 9: Capacitive current because of extra length of ESU cord, which generates electrical field on the adjacent instruments.
Bipolar Electrosurgery
The principal tissue effect achieved with bipolar electrosurgery is tissue coagulation through the process of desiccation. Bipolar electrosurgery can coagulate vessels up to 7 mm diameter%.5,19
In contrast to unipolar circuits, bipolar shows a 50% reduction in the overall amount of tissue damage, but requires more time. With the bipolar mode, there is reduced depth of penetration, less smoke is generated and the risk of perforation is less also decreased lateral spread.5,20 Another obvious advantage of bipolar over monopolar electrosurgery is the absence of a return electrode on the patient which eliminates the possibility of ground pad or alternate site burns, and capacitive coupling.3,21 In addition, it almost eliminates the risk of insulation failure. Finally, direct coupling can occur only if metal is grasped or placed between the electrodes in a bipolar circuit or extremely close to the electrodes. But the bipolar, too, has its share of problems. The visual appearance of surface coagulation may not correspond to actual full-thickness desiccation and thus there are chances that there may be over desiccation or under desiccation, both of which are problematic. As the outer layers of tissue desiccates, the resistance to current flow increases which results in lateral spread of current almost 3–4 mm and tissue heating over an additional 2–3 mm, in all directions, because of steam dispersion through tissue (Fig. 10).
With under desiccation the coagulation may cease before it is completed. This can result in bleeding. Inadequate coagulation canal so explain, in part, the occasional high rates of pregnancy following bipolar sterilization, where the tubes may be incompletely blocked.12
zoom view
Fig. 10: Bipolar current effects red area–extent of current flow (usual 3–4 mm), green area denotes extent of thermal effect (up to 3–5 mm). Lifting the tissues before current is switched on minimizes the thermal damage to underlying structures.
It canal so result inside wall injury of vessels both because of current and thermal effect. Thus retraction and lifting up of tissue from vital structures is essential. A significant problem with bipolar electrodes is tissue sticking. This can be reduced or eliminated by irrigation of the bipolar electrodes at the time of activation. The irrigant not only cools the electrodes but also the tissue, thereby minimizing conducted thermal injury. Nonelectrolytic solutions such as glycine or weakly electrolytic solutions work best.
This problem can be overcome by the use of an attached ammeter which denotes optimal desiccation indirectly by showing a cessation of current flow through that tissue. Under desiccation leads to obvious failure to achieve the desired effect.
Electrosurgery in patients with metal implants or pacemaker has to be used with care. Preferable mode to be used should be bipolar mode. In unipolar mode the ground plate should be as near to the site of surgery, as away from the implant or pacemaker, minimum time of activation and under electrocardiogram (ECG) monitoring, and care should be taken that the unit should be stopped on the slightest change in cardiac rhythm.
Do's and Don'ts
  • Inspect insulation carefully
  • Use lowest possible power setting
  • Use a low voltage waveform (cut)
  • Use brief intermittent activation versus prolonged activation
  • Do not activate in open circuit
  • Do not activate in close proximity or direct contact with another instrument
  • Use bipolar electrosurgery when appropriate
  • Select an all metal cannula system as the safest choice. Do not use hybrid cannula systems that mix metal with plastic.13
  • Utilize available technology, such as a tissue response generator to reduce capacitive coupling or an active electrode monitoring system, to eliminate concerns about insulation failure and capacitive coupling
  • Maximum contact between body and ground plate preferably under gluteus, thigh or leg
  • Do not use under bony structures such as scapula, heel or head.
Use of Electrosurgery in Laparoscopic Applications
A few safety precautions would be helpful:
  • Use up to 30 W of power.
  • Choose a smaller contact patch to achieve cutting and a larger contact patch to achieve coagulation.
  • Use the thin wire electrodes to cut and the tissue has to be placed on tension to achieve cutting and for precise bloodless dissection.
  • The foot switch or hand switch should be activated for short periods only. If the current is on long, the chance of remote site electrical injury is increased (in the event, there is an unrecognized insulation failure).
  • If the surgeon observes blanching of tissue, a precursor of charring, too much power is being used. Charring should be avoided. In the liver bed, this will result in the liver tissue adhering to the electrode and, when the electrode is moved, it will tear the liver tissue.
Recent Technological Advances in Electrosurgery
With the development of newer generators and innovative instrumentation, better delivery of the appropriate amount of energy resulting in better sealing of vessels, can now be achieved by a number of methods.
Argon Beam Coagulator
Argon gas is an inert, noncombustible and easily ionized gas that is used in conjunction with monopolar electrosurgery to produce fulguration. Essentially, the electrical current ionizes the argon gas, thereby making a more efficient pathway for the current to flow because the gas is more conductive than air, therefore providing an efficient bridge between the tissue and the electrode. The plasma beam is conducted to the area of lowest resistance during fulguration. Thus, when it is used, rising resistance in desiccated tissue, beam will move to an adjoining area of relatively lower resistance result in more limited and uniform area of eschar formation. This eschar formed with ABC is more stable and depth of 2–3 mm coagulation is achieved depending on the power- and gas-flow settings.22,23 Since ABC is non-contact in nature, it ensures that the eschar created is not pulled away which normally occur with conventional diathermy. Also less smoke is produced with the argon beam 14coagulator. Despite these advantages, the argon beam coagulator suffers from on every significant drawback in laparoscopic surgery, namely, high flow infusion of argon gas into the abdominal cavity which not only increases the intra-abdominal pressure to potentially dangerous levels, but can also result in fatal gas embolism. The effect is obviously not seen in open surgery, where it is extensively utilized in hepatic resection or for hemostasis in any solid organ.22,23
Vapor Pulse Coagulation
A unique technology called vapor pulse coagulation (VPC) produces faster, more uniform results with pulsed energy instantly delivered in a controlled manner. The energy delivery device generates up to 200 W of radiofrequency output. The energy curve is sinusoidal, with variable amplitude between 320 kHz and 450 kHz. VPCs pulse-off periods allow tissue to cool and moisture to return to the targeted area, greatly reducing hotspots and coagulum formation. This technology also results in evenly coagulated target tissue, minimal thermal spread, less sticking, and enhanced hemostasis. This technology is only available in the Gyrus PK Tissue Management System with its own innovative generator, which works in tandem with the Gyrus PK instruments. The delivery device has several settings for different applications. For the current usage, it is set up for coagulation with an adjustable setting for maximum energy delivery. In addition, energy delivery has an integral pulse-off, making delivery intermittent and thereby allowing for tissue cooling and preventing desiccation. This, in addition to a bipolar mode, enhances its safety due to minimal lateral spread of energy.24
Smart Electrode Technology
The Surg Rx EnSeal System incorporates Smart Electrode Technology. The EnSeal instruments adjust dose energy simultaneously to various tissue types in a tissue bundle each with its own impedance characteristics. This electrode consists of millions of nanometer-sized conductive particles embedded in a temperature-sensitive material. Each particle acts like a discrete thermostatic switch to regulate the amount of current that passes into the tissue region with which it is in contact, thereby generating heat within it. To keep temperature from rising to potentially damaging levels, each conductive nanoparticle interrupts current flow to a specific tissue region engaged by the electrode region. When temperature dips below the optimal fusion level, the individual particle switches back on, reinstating current flow and heat deposition. The process continues until the entire tissue segment is uniformly fused without charring or sticking. Less heat is required to accomplish fusion, as the tissue volume is minimized through compression energy, is focused on the captured segment and the vessel 15walls are fused through compression, protein denaturation, and then renaturation.25
Modified Bipolar Electrosurgery
The Ligasure System or LVSS (Ligasure vessel sealing system) utilizes a new bipolar technology for vascular sealing with a higher current and lower voltage (180 V) than conventional electrosurgery. It uses a unique combination of pressure and energy to create vessel fusion. This fusion is accomplished by melting the collagen and elastin in the vessel wall and reforming it into a permanent, plastic-like seal. It does not rely on a proximal thrombus as the classic bipolar electrocautery. A feedback-controlled response system automatically discontinues energy delivery when the seal cycle is complete, eliminating guess work and minimizing thermal spread to approximately 2 mm for most LigaSure instruments. This unique energy output results in virtually no sticking or charring, and the seals can withstand 3 times normal systolic blood pressure seals vessels up to 7 mm.26,27 This system also requires a designated generator that works with several different specific instruments designed by the company.
Ultrasonic Energy
Today virtually all laparoscopic procedures and many open surgical procedures can be performed safely and efficiently without the use of electrosurgery by utilizing ultrasound. Furthermore, ultrasonic surgery has also replaced mechanical surgical clips and scissors in many laparoscopic procedures.28
Physics of Ultrasound
  • Audible sound waves are confined to the frequency range of 20 cycle per second (Hz) to about 20,000 cycles per second. A longitudinal wave, whose frequency is above the audible range is an ultrasonic wave. When ultrasonic waves are applied at low power levels, no tissue effect occurs, as is the case for diagnostic ultrasound imaging. However, higher power levels and power densities can be harnessed to produce surgical cutting, coagulation, and dissection of tissues. This involves mechanical propagation of sound (pressure) waves from an energy source through a solid, liquid, or gaseous medium to an active blade element (longitudinal mechanical waves).
  • Ultrasonic dissectors are of two types—low power which cleaves water-containing tissues by cavitations leaving organized structures with low-water content intact, e.g. blood vessels, bile ducts, etc. It does not coagulate vessels and is used as cavitational aspirators for liver surgery 16and neurosurgery (Cusa, Selector) and high power systems which cleave loose areolar tissues by frictional heating and thus cut and coagulate the edges at the same time. High power systems (Autosonix, Ultracision) are used extensively, especially in advanced laparoscopic surgery. The harmonic scalpel and the AutoSonix system operate at a frequency of 55.5 kHz.
  • Therapeutic ultrasurgical devices are composed of a generator, hand piece, and blade. The handpiece houses the ultrasonic transducer, as tack of piezoelectric crystals sandwiched under pressure between metal cylinders. The transducer is attached to amount, which is then attached to the blade extender and blade. The harmonic scalpel cools the hand piece with air while AutoSonix and Sonosurg systems rely principally on large diameter hand piece made of heat dissipating materials to remove the heat and prevent heat buildup.28,29
Ultrasonic Cutting, Coagulation and Cavitation
  • The basic mechanism for coagulation of bleeding vessels ultrasonically is similar to that of electrosurgery or lasers. The difference is that with ultrasonic probes vessels are sealed by tamponading and coapting with a denatured protein coagulum by mechanical energy of the vibrating probe as opposed to thermal injury.
  • Ultrasurgical hook, or spatula blade can coagulate blood vessels in the 2 mm diameter range without difficulty and the scissors can coagulate vessels up to 5 mm in diameter. Heat generated with the use of dissector is limited to temperature below 80°C. The overall temperatures achieved by the dissector, even after prolonged use, remains well below the 250–400°C achieved with electrosurgery and laser surgery. This results in reduced tissue charring and desiccation and also minimizes the zone of thermal injury. Skin incisions made with the ultrasonically activated scalpel or cold steel scalpel heal almost identically and are superior to electrosurgically made incisions. The minimal tissue damage may explain the marked reduction in postoperative adhesions to the liver bed following laparoscopic cholecystectomy with the ultrasonically activated scalpel, when compared with electrosurgery or laser surgery.
  • Although coagulation produced by ultrasonic surgery is slower than that observed with either electrosurgery or laser surgery, nonetheless, it is as effective or even more effective, because despite the slower rate of tissue coagulation, the entire process of tissue coagulation combined with transection, the ultimate goal of surgery, is faster with the ultrasonic scalpel than with other energy modalities. However, greater depth of thermal injury can result with ultrasonic dissection ultrasurgery, as compared to electrosurgery, if activation of the probe persists for more than 10 seconds.17
    zoom view
    Fig. 11: Different energy sources all ultimately result in protein denaturation.
  • The mechanisms of coagulation also offer an advantage for ultrasonic surgery over electrosurgery with regards to the sidewall of a blood vessel. Blood vessels are usually not coapted significantly by electrosurgery because of the concomitant reduction in power density. Furthermore, the blood within the vessels has a high heat capacity and acts as a heat sink, which allows one side to coagulate prior to the other, with resultant bleeding from a hole in the wall of the vessel that was in contact with the electrosurgical device. But with the ultrasonic shears the blood vessel can be gripped and then coagulated (Fig. 11).
  • Absence of coagulated tissue sticking to the active element, because of the vibration of the active blade, is another unique feature of ultrasurgical coagulation compared with other energy modalities. In addition, the grasper blade allows unsupported tissue to be grasped and coagulated without difficulty, or cut and coagulated as with scissors.
  • The cutting mechanism for the ultrasonically activated scalpel is also different from that observed with electrosurgery or laser surgery. At least two mechanisms exist. The first is cavitational fragmentation in which cells are disrupted. This occurs primarily in low protein density areas such as liver. This mechanism is utilized by the cavitational ultrasonic aspirating device (CUSA). The device is composed of an ultrasonic generator that vibrates at 23,000 Hz. When coupled with powerful aspiration device, the ultrasonic aspirator fragments cells and aspirates the resulting cellular debris and water. This action leaves collagen rich tissues such as blood vessels, nerves, and lymphatic intact. Thus, there is no cutting or coagulation with the ultrasonic aspirator. In marked contrast, the ultrasonically activated scalpel not only coagulates and cavitates, it also cuts high protein density areas such as collagen or muscle rich tissues. This occurs via the second cutting mechanism, which is the actual “power cutting” offered by a relatively sharp blade vibrating 55,500 times per second over a distance of 80 µm.18
  • A major advantage of the ultrasonically activated scalpel's coagulation ability is the absence of melting and charring of tissues. This allows the tissue planes to be clearly and sharply visualized at all times. The ultrasonically activated scalpel can also be used as a blunt dissector to aid in identifying tissue planes. However, the high power ultrasonic dissection systems may cause collateral damage by excessive heating and this is well documented in clinical practice. Ultrasonic surgical dissection allows coagulation and cutting with less instrument traffic (reduction in operating time), less smoke and no electrical current.2830
(LASER: Light Amplification through Stimulated Emission of Radiation)
The laser beam is generated in a cavity (Fig. 12). By using a foot pedal, the surgeon has three options as to how the laser beam can be released from the cavity. The first mode is known as the continuous wave (CW) where the beam continues to be emitted at a steady rate. In the pulse mode (PW), the pulse is released for a limited period of time at a higher peak power and the Q switched mode where the energy is released in exceedingly narrow pulses in very high peak power. This type of laser is used frequently in ophthalmologic procedures and the power in these lasers tends to be measured in milliwatts. High power and short pulse duration are the hallmark of ophthalmologic lasers (Fig. 13).
Unique Properties of the Lasers (Table 1)
  • First the light is monochromatic. The laser emits light over a very narrow, well-defined wavelength.
  • Second, the light is coherent. Because of the properties of stimulated emission, laser light is perfectly in phase; that is each peak and valley of the sine wave curves align exactly.
Finally laser beam is virtually nondivergent (up to 1° of divergence), giving a highly focused beam.
zoom view
Fig. 12: Method of laser generation.
zoom view
Fig. 13: Methods of release of laser beam.
Table 1   Properties of commonly used lasers.
within near 1,064 nm
Far infrared region 10,600 nm
Infrared region 450–528 mm
2,010 mm
Energy reflected (Back scatter)
30–40% So cannot act effectively
Effective depth of penetration and coagulation
3–4 mm
0.1 mm
1.0 mm
1.3 mm good cut good coagulation
Transmission through fibers
+ can
– coagulate/cuts
– endoscopic use
Poor transmission through fibers requires mirrors
Fibers transmission ++
Glass fiber ++
Transmission through liquids
Heavily absorbed by water vaporizes and cuts
Heavily absorbed by hemoglobin or melanin pigments
Clinical use
Good coagulation
Superficial skin lesions ENT Good cutting
excellent cut
Blood vessel coagulates
Stone fragmentation
Biophysical Principles of Lasers
The biophysical effects can be described as:
  • Electromechanical: Dielectric breakdown in tissue caused by shock wave-plasma expansion resulting in localized mechanical rupture.
  • Photoablative: Photo-dissociation or breaking of molecular bonds in tissue.20
  • Photothermal: Laser light generates heat which heats and vaporizes tissues.
  • Photochemical: Target cells are induced by laser light to chemical reactions.
  • Holmium laser vaporizes water inside the stone causing thermal expansion and calculus disintegration.
There are a number of types of laser available. The major types of medical lasers available commercially today, are all named after the medium in the laser cavity.
Laser Tissue Interaction
It depends upon:
  • Wavelength
  • Power density
  • Exposure time (3 types available) Q-switched, pulsed and cautious wave
  • Absorption and scatter.
Depth of penetration denotes extinction length or the tissue thickness at which 90% of laser beam has been absorbed. The effect generated:
  • Is directly proportional to the time of application more than the power rating.
  • Is inversely proportional to distance from tissue.
  • Some cooling at the surface of application results in lesser vaporization at surface and deeper penetration (blooming effect).
Specific properties:
  • Nd:YAG, CO2 and argon lasers.
  • All three of the above lasers work fundamentally by thermal action. When tissue is heated by any of these lasers up to 60°C, there is no permanent or visible damage to the tissue. By 65°C, denaturation of protein occurs. The tissue will visibly turn white or gray and will disintegrate approximately 4–7 days later. This is the temperature range in which the Nd:YAG laser works. Once tissue has been heated to 90–100°C, there is tissue drying, some shrinkage, and permanent damage due to dehydration. Over 100°C, carbonization or blackening of tissue occurs. As the temperature rise continues, there is evolution of gas with tissue vaporization. This is the temperature in which the CO2 and argon laser works.
  • Argon-pumped dye laser: The only laser system that does not work by the thermal cavity is combined with hematoporphyrin derivative. In this laser system, hematoporphyrin derivative is administered intravenously 48 hours prior to therapy. The hematoporphyrin derivative is concentrated within the tumor cells in preference to the normal cells in certain organ system of the body including the bladder. When exposed to the red light, the hematoporphyrin derivative is excited and cleaves oxygen to from 21singlet oxygen within the mitochondria, leading to cell death. This is a nonthermal effect.
  • Holmium:YAG laser is based on a mixture of helium and neon gas is visible as red light. It is used as a guiding medium for nonvisible lasers and also for stone disintegration by vaporization of the water inside calculus causing thermal expansion and calculus disintegration.31,32
  • Excimer laser uses rare gas halides as the medium. It lies in the ultraviolet spectrum. Maximum usage in ophthalmology and laser angioplasty.
  • KTP/YAG laser (wavelength 532 nm) is the green light laser. Potassium-titanyl-phosphate which is used to guide the beam of Nd:YAG laser is visible as green light. It is used in prostatectomy, and skin lesions.33
Visible and Invisible Lasers
  • Visible lasers are located in the wavelength between 400–700 nm. Best examples are argon and KTP laser.
  • Invisible lasers are located in the range of 700 nm or more. The best examples are Nd:YAG laser, carbon dioxide laser.
Common Complications
  • Skin related—skin burn.
  • Photokeratitis, skin malignancy
  • Eye—thermal retinal damage, corneal burn and cataract.
High-Velocity Water Jet Dissection or Hydro-dissection
Pulsatile high-velocity high-pressure water or crystalloid jet dissection involves the use of relatively simple device, produces clean cutting of reproducible depth. In hydrojet technology very thin water jet produced which acts almost like a cutting knife. It requires a special hydrojet generator and produces high-pressure jet of between 20 BAR and 60 BAR. Water stream under high pressure (hydrojet) is used to facilitate tissue dissection and release adhesions. Other advantages are the cleansing of the operating field by the turbulent flow zone and the small amount of water required to complete dissection. A relatively hemostatic method which exposes the blood vessels or biliary channels, once parenchymal dissection has occurred, which can then be dealt with appropriately.34,35 Specific problems were identified with the use of this modality. The “hail storm” effect results in excessive misting which obscures vision. This has been solved to some extent by incorporating a hood over the nozzle. Difficulty in gauging distance and thus poor control of the depth of the cut are drawbacks. The spraying of tissue fragments also renders the procedure oncologically unsound. The present use of water-jet dissection is limited to dissection and resection of parenchymal organs, 22including liver, gallbladder, brain, kidney, prostate, lymphadenectomy and pleurectomy in thoracoscopic surgery and to cleaning wounds.34,35 Other uses include, in orthopedic surgery for cutting and endoprosthesis and bone, in dental use for cutting and grinding of dental materials, in plastic surgery for cleaning skin graft, removal of tattoos, and liposuction and for dermatological lesions. The fluid used can be combined with an anesthetic agent or an antibiotic to reduce the pain and prevent infection. Microwave water jet scalpel is another application of the water flow. It is used for minimally invasive removal or resection of tumors. It is a combination of a microwave scalpel and a jet system.
Radiofrequency Ablation
Radiofrequency (RF) ablation is a minimally invasive method that uses thermal energy to destroy tumor cells in organs such as the lung, liver, kidney, benign bone tumors, pancreatic cancer and also biliary cancer. The tumor is located by a computed tomogram or an ultrasound scan. Energy is then delivered through a metal tube (probe) inserted into tumors or other tissues, under ultrasound guidance. When the probe is in place, metal prongs open out to extend the reach of the therapy. RF energy causes atoms in the cells to vibrate and create friction. This generates heat (50–100°C) and leads to the death of the cells. However, temperature controlled RFA can also be used. The efficacy of treatment is assessed by CT scan one month following treatment. Retreatments are often necessary. Risks of the procedure include bleeding, although this is extremely rare. It also finds use in heart tissue to destroy abnormal electrical pathways that are contributing to a cardiac arrhythmia. Thus it is used in recurrent atrial flutter (Afl), atrial fibrillation (AF), supraventricular tachycardia (SVT), atrial tachycardia, multifocal atrial tachycardia (MAT) and some types of ventricular arrhythmias.
Recent advances in treatment of varicose veins include varicose vein ablation by RF delivered with the help of a thin catheter. So also nerve ablation can be done to reduce the chronic pain of arthritis or lower back pain. Chronic lower back pain (CLBP) is also an area amenable to RF. The causes of CLBP tend to be multifactorial. Arthropathy of the lumbar facet joints is thought to be a common etiology (15–45%). RFA of the medial branch nerve of the facet joint is a well-established treatment modality used to decrease facet joint pains. A wide range of temperature is being used (70–90°C) but the optimal temperature that provides the best patient outcomes with the least side effects is not well established in the pain management literature.36,37
Microwave Ablation
An alternative means of producing thermal coagulation of tissue involves the use of microwaves (MW) to induce an ultra-high-speed (2,450 MHz) 23alternating electric field, causing the rotation of water molecules. Although the use of MV for tissue ablation is not new, the majority of the clinical experience with technique is with ablation of liver tumors. Percutaneous microwave ablation (PCMWA) was first used as an adjunct to liver biopsy in 1986, but it has since been used for hepatic tumor ablation. As with RFA, MWA involves placement of a needle electrode directly into the target tumor, typically under US guidance. MW energy spectrum ranges from 300 MHz to 300 GHz to produce tissue-heating effects. Each ablation also produces a hyperechoic region around the needle, similar to that observed with RFA. Unlike RFA, however, no retractable prongs are used, and the resulting ablation tends to be much more elliptical. For isolated, nonmetastatic lung tumors, surgical resection remains the treatment of choice. However, many patients are precluded from surgery due to poor cardiopulmonary function, advanced age, or extensive disease burden. For these patients, minimally invasive therapeutic options such as RFA, MWA, and cryoablation have emerged as possible alternatives. Tumor ablation of thoracic malignancies should be considered a viable treatment option for patients with early stage, primary or secondary lung cancers who are not surgical candidates or for patients in whom palliation of tumor-related symptoms is the intent. MWA is regarded as a particularly efficient option for the treatment of lung tumors since unlike RFA it does not rely on impedance to generate heat, rather electromagnetic microwave waves heat matter by agitating water molecules in the surrounding tissue, producing friction and heat.38,39
Cryotherapy uses the principle of rapid freezing and slow thawing of the tissue in multiple cycles. These temperature changes affect several intra- and extracellular mechanisms leading to cell membrane disruption and thrombi formation in the blood vessels inducing apoptosis and ischemia.40 Delayed effects include loss of microcirculation leading to anoxia and stimulation of cytotoxic T cells.41 The cryogens used are liquid nitrogen, nitrous oxide and liquid carbon dioxide. Liquid nitrogen has became the most popular cryogen as it is easily available, lack explosive potential, freeze tissue up to –197°C and predictable effect. The application is carried out through 3 mm or less probes. The application of ultracold liquid causes damage to the treated tissue due to intracellular ice formation. The osmotic gradient created by these crystals facilitates cell destruction by drawing water out of the cells. In addition, the cell membrane composed of lipid bilayer is also sensitive to hypothermia. During the cooling process, the membrane becomes highly permeable and allows mass transfers of ion, resulting in destructive changes in the ionic composition of the cell. The thawing process is the final step when the crystals dissolve due to increased temperatures, creating a reverse osmotic gradient. 24Water reenters the cells, causing swelling and rupture. Furthermore, it has also been hypothesized that freezing results in vascular injury by causing stasis in blood flow. The resulting ischemia causes cell death by necrosis. The degree of damage depends upon the minimum temperature achieved and the rate of cooling. The gas is then switched off once the desired temperature is achieved. The tissue is allowed to thaw which leads to the cell destruction by hemorrhagic infarction. The cycle of freezing and thawing may then be repeated, a process known as “double freezing.”
The uses of cryotherapy are esophageal premalignant lesion, bone tumors, hepatocellular carcinomas, precancerous condition of cervix, nephron-sparing kidney cancers prostate cancer, retinoblastoma and in the palliation of hepatocellular carcinoma (HCC) and liver metastsis.4042 It is also widely used in various skin conditions such as skin cancer, actinic keratosis, warts, moles, skin tags, and solar keratosis. The application of cryotherapy can be in both by open and, laparoscopic surgery. Cryotherapy can also be applied as ice-pack therapy, cold spray anesthetics and whole body cryotherapy.
In present era, wide range of energy devices are available, which are appealing and also safe alternative for cutting, coagulation and dissection. Its use in surgical practice has increased the versatility of the surgical procedure and decreases operating time. The use of energy devices in surgical practice depends on the task, surgeon experience, availability and cost. Monopolar and conventional bipolar electrosurgery are used freely, as it has wide range of dissection capability and cost effective. Because among the most commonly used sources, there is no major difference among their results. The only reason to select one over the other would be the site of application and the requirement.
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