All right, good evening, everyone. Welcome to the Augs Neurogynecology webinar series. I'm Dr. Colin Johnson, member of the Augs Education Committee and the moderator for today's webinar. Today's webinar is entitled, Don't Get Burned, Electrosurgery in the OR. Our speaker today is Dr. Benjamin Barron. Dr. Barron is an associate professor in obstetrics and gynecology, as well as the chief of complex gynecology at the Medical College of Wisconsin in Milwaukee, Wisconsin. He completed the Fellowship in Minimally Invasive Gynecologic Surgery at Cleveland Clinic, Florida. His practice focuses on surgical management of gynecologic conditions, particularly endometriosis and uterine fibroids, and he also performs and interprets gynecologic ultrasound. So before we begin, I'd like to review a few housekeeping items. The presentation will be about 45 minutes, and the last 15 minutes will be dedicated to question and answer. And Augs designates this live activity for a maximum of one AMA category one credit to claim the CME credit, you must log into the Augs e-learning portal and complete the evaluation after the webinar. It is being recorded and live streamed, and a recording webinar will be made available in the Augs e-learning portal. And then please use the question and answer feature of the Zoom webinar to ask any of the speakers questions, and we'll answer them at the end of the presentation. And then use the chat feature if you have any technical issues. Augs staff will be monitoring the chat and can assist. And you can go ahead, Dr. Barron. Okay, thanks, Dr. Johnson for the kind introduction. And thank you also to Augs and to Dr. Johnson who also invited me. I don't think he shared that Dr. Johnson was one of the residents at our program, so we've known each other for a little while. And he asked me to do this because I typically give a lecture similar to this to our residents on a kind of recurring basis because I just really think it's important to know how our instruments and especially electrosurgery works in the OR. It's usually a bit more complicated than we recognize, but I think hopefully through this session I can present that it's still understandable and helpful for us all. So just for disclosures, I do have a disclosure here, but I do not find that it's relevant to this talk at all. So my goals today are to help go through terminology for electrosurgery, helping to kind of remove inappropriate terms and help encourage the appropriate use of terms. I also want to highlight the differences between electrosurgical waveforms because that really highlights just the different features and how you can utilize the instrument appropriately. And then also to help everyone here today to kind of choose the appropriate applications of electrosurgery during procedures in the future. So in general, I think we'll find that electrosurgery is not understood by a lot of surgeons, but yet we use it almost all the time. There's barely a case that goes by that some sort of electrosurgery is not being used. And we all know that if you're not using it well, or even if you're trying to, there can still be some complications that come to the patient or to the surgical team. These can lead to litigation issues, which kind of harm patients or the surgical team, and also just can have an effect right anytime we cause complications for a patient that has an effect on us as well, kind of with the second victim syndrome. So I always think the most important thing in the operating room is good communication with your team, and even just across healthcare, right, as we try to communicate across institutions to really be able to tell people what we're doing. It's important that we all have the same terminology and that we speak similarly so that others can kind of emulate what we're doing. Now I'll highlight some of the terms that I find that are incorrect, yet these are probably the terms that we are using on a regular basis in the operating room. So BOVI is probably something that we say very commonly in the operating room to refer to an instrument, yet BOVI was the man who invented some of these surgical instruments or the electrosurgical generator that allows us to do electrosurgery. And then oftentimes we're saying cautery or cauterize things, but ultimately that's also not really something that we do in the operating room. Cautery is really just something getting very hot and you're transferring that heat to something else and resulting in tissue destruction. So I often compare it to like branding cattle or something like that. And again, that's not what we're doing. Burn, right? I mean, tissue does get burned. There is a tissue effect that happens, but ultimately that's also not the correct term. And grounding pad, something we all say, right, but ultimately our patients or none of our instruments are ultimately plugged into the ground, so it's not a correct term. Now, I will recognize that these terms, if you want to talk about efficiency of communication in the OR, if you're talking to your scrub techs or your nurses, these are the terms they use. So it is probably appropriate to say those things in the operating room so you can get the team to grab what you need or address the items that you need. But amongst professionals and things as we're speaking with learners or, again, across institutions or at meetings or publications, we should really be focusing on the more correct terminology. And ultimately there was a publication in JMIG a few years ago, well, I guess about nine years ago now, that lists the appropriate things. And I'm going to highlight a few of these later, bigger. So right now it may appear slightly small to you, but kind of the important ones. But this is actually what's recommended. If you're submitting a paper to JMIG, you need to be using terminology from the green rows. You're not to be using terminology in the kind of pink rows. But if you can read some of those, you'll see that a lot of those ones in the pink ones are the terms that we're probably using on a daily basis in the OR a lot. So electrosurgery is all based upon just electricity, and so we're going to just take some steps back and just kind of focus on that. This might take you back to some college physics or something like that. But electricity is just the flow of electrically charged matter. And that electrically charged matter follows a path, and in electricity, we call that a circuit. And on that circuit, there's a relation that we call Ohm's law. So V equals IR, V is voltage, I is the current and R is resistance. And it just tells us how the electric current flows based on various conditions. So, for example, if we have a circuit that has some sort of constant voltage applied to it, if you increase the resistance, you're going to get a decrease in the current. Or similarly, if you have constant resistance, but you increase the voltage, you're going to get an increase in your current. And you can do various changes to that to see how those interplay. So in the operating room, we have circuits. So we have a power source, if we try to add things to this basic cartoon at the bottom, we have a power source. We have our wall plugs and our electrosurgical generators. Our current is conducted through our instrumentation and cords. And ultimately, our resistor, in this case, is the patient. And so I just wanted to highlight just the idea of a circuit again, because it's going to come into play a little bit more. I'm going to stop sharing my slides and hopefully you'll be able to see me back here. So I have one of my children's toys here. It's called a snap circuit. It's like they get to build like Legos almost type thing and you just design little circuits and you have fun with them. But essentially, you can see here we've built a circuit. This one has a switch in it so I can control it on and off. When we do that, you see the little fan and lights get going, right? But if I break the circuit and pop this piece off, then nothing's happening, right? So the circuit has to be a closed loop, right? Underneath this blue tape are the batteries. So it's kind of like our electrosurgical generator. We have these little kind of metal pieces that connect it. And then we have our effects, right? So you got to remember a circuit has to be a closed path for the electricity to flow. Let me get back here to my slides now. All right. So going again into some of the details of that circuit that we're using in the operating room, it all starts at the wall plug. That's where our electricity is coming in. I'm not going to get into how the electricity gets there. I think that's a little bit out of the scope of this lecture. But first, we have some poll questions just to try to make sure people are staying engaged. But do you know which type of current is coming from a standard US wall plug? So our poll question is giving you the option of A, AC, alternating current. Choice B, DC, direct current. Or C, if you just don't know. We'll give people a little bit here to respond. And let's see if we can get the results up. So 90% of people responded AC, alternating current. No one said DC, direct current. And only 1%, 10% did not know. And that's correct. So the majority are correct. That the current from a US wall plug is AC, alternating current. And so this essentially means if we think of the electrons or the charged particles, they're not flowing just one direction in a loop. They're alternating directions going back. And then in the US, when you have a wall plug, there's going to be a set voltage and a frequency that's out. So the voltage of a US wall plug is 120 volts. And the frequency of the alternating current is 60 hertz. So that means that the direction of the electrical current is alternating 60 times a second. So if we think about this, if we applied 120 volts of electricity at 60 hertz to a patient, just think in your mind, what do you think would happen? Is that what we're doing in the operating room? If you're not quite sure what happened, you probably do know what happens if you look at this picture. If you were to just stick a fork into a electrical plug, I think we all know what happens. That's not going to be good. So it's pretty clear that the electrosurgery we're using in the OR is not 120 volts and 60 hertz. And this brings us to the piece that really helps us safely administer electrosurgery in the operating room. And that is the electrosurgical generator. And I usually try to think that there's multiple important tasks for this. But the first one is that it's amplifying the frequency of the electricity. So neuromuscular stimulation, or essentially electrocution, happens at ranges less than 100 kilohertz. So if we go straight from the wall plug at 60 hertz, it's well within that range. But for electrosurgery, it's bumping it up to the range of about 200 kilohertz to 3.3 megahertz. And if we see, that's where it starts getting into the radiofrequency. So if you see the top arrow for the neuromuscular stimulation is landing kind of, I mean, it's landing just above the 50 hertz on there. But and then the radiofrequency, so the electrosurgery part, is the bottom arrows. And then that really brings us to the proper term that we're using radiofrequency energy, electrosurgical energy for our patients. And to help visualize how this different frequency is important in the neuromuscular kind of stimulation is, if you think of this little cartoon here I made, and we'll activate the animation here in a second, but the blue ovals are just charged particles, so ions in the cell. And if we apply, you know, maybe 60 hertz of electrosurgical energy, you'll see what happens. In the yellow, think of that as like a cell membrane. And so as this goes, because the frequency alternates slow enough, the ions have time to travel back and forth across the cell membrane. And opposite, if we're up above 100 kilohertz, same thing, now when we do it, we see that the frequency is alternating so quickly that those ions never cross the cell membrane. And hopefully that animation showed up okay and didn't lag on you. But, and that's the whole idea then, that above that point, the ions are going back and forth so quickly, they're not crossing cell membranes. So you're not getting depolarization and essentially neuromuscular stimulation. But also the whole concept of those ions moving, that's the whole way that the radio frequency energy works in the OR. So when you're applying your electrosurgery or radio frequency energy through your instruments, essentially what's causing, or what's happening is the current you're applying is alternating, it's moving ions within the cells. Again, it's too frequent to cross the cell membranes. And just that movement of the ions creates friction, which leads to heat. The heat causes water in the cells to vaporize, the cells then desiccate or dry out, and you get your tissue effect from that. So that's how it happens. So it's not just a simple, like we've said before, it's not just cautery where we're taking something hot and applying it. Certainly we do create heat in the process. Now, when we use radio frequency energy, we have the two different choices of instruments being either monopolar or bipolar. And the difference here is not that they're using any sort of different current. Both of them are still using alternating current. And both of them still have two electrodes, and they're still using alternating current. And both of them still have two electrodes, or at some point where the circuit is involved. But the difference between monopolar and bipolar is that they're just in different locations. So monopolar instrumentation has one electrode on the instrument, and then there is a second electrode elsewhere. Most often it's going to be a pad. Bipolar, on the other hand, again, still has two electrodes, but both of them are within the instrument. So the example here in this picture is this bipolar grasper, where one electrode would be one paddle, and one would be the other of the grasper. So then if we look at the monopolar instrument circuit in the operating room, again, we're starting at the electrosurgical generator. In this case, we have a monopolar pencil, which is transmitting to the patient, and then going back through a pad to the electrosurgical generator. Now, for simplicity's sake, this diagram shows one direction of flow for the electricity, but remember, it's all alternating current. So actually, constantly within that circle, the electricity is alternating directions. For bipolar, just to visualize that, again, starting at the electrosurgical generator, the current is going out through the instrument, through the patient, and then back through the instrument. It's all self-contained. Again, same thing. This is alternating current. It's not unidirectional, like the arrows show. The arrows are unidirectional just to make it a little easier to understand. So if we go back, we were talking about circuits before, right? There's voltage, and there's current and resistance along it. And really, the current through a circuit is always going to be the same, no matter where you are in the circuit at any time. So when we activate our instruments at the patient, we see some sort of tissue effect, right? Hopefully, it's not fire, as the diagram shows there, but we're getting some tissue effect. Some tissue effect, tissues cutting. There can be some burning effect of tissue. But we don't necessarily see that on the other side, right? But yet, the current is the same throughout this path, through this circuit. And so you have to stop and think, so why is that? But what is so different about this between the instruments and the pad side? Because again, we're only seeing tissue effect at the end. When we take the pad off the patient, we're not seeing a burn at that point, or we better not be. And this has to do with the size of the electrode. At the tip of the monopolar pencil, it's very small. So all that current is being focused through a very small point. So the current density is extremely high and focused through a small area and thus you're getting a tissue effect. Whereas with the pad, it has a very large surface area. And so it's spreading out all of that current. And so you get a low current density and it keeps it at a point where you are not getting a tissue effect. And this finally gets us to the proper name that this is not technically a grounding pad, but it is a dispersive electrode because it's really, it's spreading out that current over a large enough area where there's not gonna be a tissue effect. And so again, dispersive electrode should be the preferred term that we use in our professional communications. Not saying, you know, grounding pad, return electrode. Again, return electrode would not be accurate because again, the electrical current is going both directions, not just one direction. So then it comes to think, so oftentimes our dispersive electrode is on the patient underneath drapes and we don't see it. And so then we worry, well, what happens if the pad, you know, peels off to where it's attached to just one small point? And so I'm gonna stop my slides here again and bring up some other piece here. All right. So if you can still see me in a little window, but the big screen, you see a picture of an electrosurgical generator sitting at the table across from me. And kind of down at the bottom left, just above the blue plug, you see a little light that says alarm and it's red right now. But now if I put this pad on my arm, we see that it turns green. So this means that everything's good, that the dispersive electrode is in good contact. But if you watch what happens as I start to peel this off, it turns red and an alarm goes off. And I'm sure you've all heard this alarm at some point in the case. And so that really means that the pad is peeling off, right? So then what you need to do is you need to have someone push that pad back on and you can see it's green again, right? And so this is a safety feature of the pads. It's called return electrode monitoring to help prevent unintended tissue effect at that level. And essentially how that's going on, let's stop sharing here for a second. Sorry, I went too deep. All right. If you see the bottom side of this specific pad, it essentially has two separate rectangles divided by a darker blue rectangle. And so the generator is constantly trying to send a low voltage or current between the two sides of the pad. And so it needs to know that they're both in contact. And as you start to peel one up, it can't send that through and the device knows that it's not plugged and then it's not safe to use. And so it deactivates and it won't allow you to administer the energy. All right, get back to the slides here. So again, yeah, so we call that return electrode monitoring. Some electrosurgical generators will say REM on it. And again, it's just making sure it's in good contact so we're not getting unintended tissue effects at sites away from our surgery. Another thing that our electrosurgical generators are doing is just an isolated circuit check. It's also making sure that when a current is delivered, that the current must go back to the generator. And this is an attempt to minimize any sort of stray current. So this is a concern like why we don't want patients to have metal piercings or something, right? Potentially a spot where a current could try to get passed off to the OR table or anesthesia wires or something like that. And so with the dispersive electrode, there's kind of some best practices. I think it's pretty nice since all of us are pelvic surgeons, we're kind of operating in one location so we can have a pretty standard setup for this, right? You wanna place your dispersive electrode over a well-vascularized muscle mass. You want to orient it transversely to the path of the current. So if you see, I've put some green arrows at the bottom that are going towards the wider side rather than the red. Again, that just helps that the electrical current will be hitting a larger area. You wanna avoid irregular body contours, bony prominences, scar tissue, adipose tissue. Choose a site that's pretty close to the surgical field and you wanna make sure that it maintains full contact. But again, our electrical surgical generators are gonna tell us or alarm if that's not happening. And so for us as pelvic surgeons, typically we're putting this on the thigh somewhere. All right, so we've got our pad in place. Now we're ready to actually finally use our instruments. And then it comes down to whichever instrument you're choosing and how you activate, there's multiple options. If we're talking about a monopolar instrument, right? So if you have maybe a laparoscopic scissors or Maryland that you're hooking up your radio frequency energy to, you have maybe a foot pedal with two different buttons. If you're using a standard monopolar pencil, you have your two buttons to choose from. Or if you're a robotic surgeon, you got a lot of buttons to choose from, but really for each instrument, right? You have either a blue or yellow button to choose from. And essentially the difference between the two buttons is something called the duty cycle. And the electrical surgical generator is going to give different duty cycles and even some voltage differences based off which one you use. And that's gonna give you different tissue effects. So then the duty cycle is essentially the generator saying, how often is the current on and how often is it off? And so one option is that it's just continuous so that when the instrument's being activated, it's delivering just a continuous flow. So if you show the current on there, again, because it's alternating currents, it might be more sinusoidal than jagged like this, but you get the point that if you had an amp meter, you would just see this constant flow uninterrupted. But the other option is that it's interrupted and kind of a standard one, although there's different ones, is that means like 6% of the time it's on and 94% of the time it's off. So the current in that case would look more like this. You get a quick burst and then there's a pause and then you get a quick burst. And in general, when using a continuous waveform, it's gonna function at a lower voltage and the interrupted ones are at a higher voltage. And then this comes into our more colloquial names, such as the continuous waveform is cut, which if we think on a monopolar pencil is gonna be the yellow button. And the other is the coag button, right? The blue button on the pencil. And so that's the difference. When you choose between the two different buttons, you're administering a different waveform, either a continuous waveform or an interrupted waveform. So your other choice when you use this is whether you're gonna have your instrument contacting the tissue or is it not in contact? And then this is where you get the variety of effects. So if you choose the cut option and you put it in contact with the tissue, you're gonna get desiccation, all right? So it's going to cause drying out of the water and it's gonna get a nice deep effect. Versus if you use a non-contact, you get vaporization. And the effect here is definitely where it's actually just cutting the tissue, right? It's making the tissue disappear. But as you can see, the tissue that remains, it's not getting like a very deep, like thermal injury or anything like that. Now it's easy, contact with your coag is also called desiccation. So it's the same thing. With your coag is also called desiccation. So it's the same thing. But as you can see, it does not go as deep. And the reason for that is because with this high voltage you're applying, even though it's interrupted, you're creating much quicker kind of char and desiccation of tissue. So that further attempts at delivering the electrical current into the tissue, it can't penetrate anymore because it's essentially been kind of shut down. The electrical current can't find a path. Whereas for the cut, since you're using a lower voltage, that process happens slower. So as you continue to administer it, the tissue doesn't get fully desiccated right away. It can kind of travel a bit deeper into the tissue to have its desired effect. And then if you use the coag button in non-contact, this is where you get, it's called fulguration, right? And so this is where it's kind of widespread. Again, pretty superficial, but you get a more widespread coverage. And then those, again, play into the terms that we should be using when we're talking, right? So if we're trying to describe to someone how we're doing surgery, right? We should be talking about whether we were vaporizing or fulgurating or desiccating and what waveform are we using? Are we using continuous or interrupted? And that way that one of our surgeon colleagues at another institution can understand, okay, this is what we're doing. This is how I can emulate that in the same way. It's much more specific than just saying something like BOVI or burn or cautery, which are terms that at least professionally we should try to stay away from. All right. So then the big debate, the big question, I feel like this is something we probably all ran across as interns doing C-sections or at various other times, but let's say you have a little bleeding vessel, you grasp it with a hemostat or pickups, and then someone gave you the monopolar pencil and said, okay, like hit this. Which button are you gonna press? So we're gonna bring up a poll. We can see what people would choose. So the options here, so again, so what button should be pressed on a monopolar instrument when performing direct coupling? And again, direct coupling is when we are just using an instrument to essentially extend our instrument's electrode. So A, the blue button, which is known as coag, B, the yellow button, which is known as cut, C, it just doesn't matter, or D, both. Give a little bit more time for people to think and respond. And then we can bring up the results here in a moment. All right, we have a little bit more split here, although a lot of non-committals, only four responses here, but 25% said the blue coag, 50% said the yellow cut, and 25% said both. And so the answer here is actually the yellow cut button. It does matter, and it's important. So the largest percentage at least did get that right. And let's kind of go into why again. So the yellow button is the correct one. So this is where I like to bring up my kind of grilling and meat analogy. So if you remember back to the slide where we were showing the coag, where we were showing the two different types of desiccation with the cut or continuous waveform in contact, we saw that it had a nice deeper penetration, whereas the coag or interrupted in contact was not as deep, right? So I think about this like if you're cooking a steak on a grill, if you want a steak that looks like this on the left, where it has a nice charred outside, and it's pretty rare in the middle, I'll admit that's pretty rare for my liking there, but you're gonna use the kind of coag or interrupted flow because that's gonna give you that really high voltage that's gonna get that high char on the outside. And some people really like that when you're doing this because you think that you're getting better burn, right? It's gonna potentially create more sparks. There's probably gonna be more smoke. It looks like you're doing a lot more, but it's all superficial. It's all on the outside. Versus if you go the low and slow method, if you're more like smoking meats, like a brisket there, using the cut waveform that's the continuous, you're going lower, right? So it's allowing that heat to penetrate more over time, and it's getting deeper. And then if we think about how you want the blood vessel that's bleeding to look like afterwards, right? We'll want the blood vessel to look more like the brisket. It's fully cooked all the way through, not like the rare steak on the side, right? Where it's charred on the outside, but everything's still normal and healthy in the middle. So the yellow button, the cut button is the proper one to use when you're trying to use direct coupling for a bleeder. But then we get to bipolar options, right? I mean, so we do have different waveforms to choose from, but most often if you start thinking about, well, when I use bipolar instruments in the operating room, I don't really have a choice, right? I just have one button to choose from. So whether you're using, like if you use any sort of bipolar graspers, you may have a foot pedal like the one on the left side, or if you're using some of the bipolar disposable devices, right, there's really only one activation button on it. So what is that? Well, it is only actually cut or continuous, which is good, right? We just talked about when we have our electrodes in contact with the tissue, if we want a nice deep tissue effect, we wanna be using the cut or continuous waveform. But I'm gonna kind of go into why that is as well, and perhaps how we've learned this over time. These slides are busy, but I think this is just really helpful. I've brought in a few examples from different generators. And so some of you might recognize these ones as one that you use, but only if you don't, I would encourage you to speak with your rep, or you can look up online for the one you have to try to find this. And you can find that what essentially the voltages in the operating frequency are. In different ones, they'll say different things, so you might have to look a little bit different, but I've tried to highlight yellow, right? So if you remember that the yellow cut, the continuous waveform tends to be lower voltage in a constant uninterrupted form. So you see here, the frequency is constant. Whereas when you get to the coag, you see this one is pulsed, right? It's interrupted and it's using much higher voltages. But then if we use, if we look at the bipolar feature at the bottom, then the voltages are low again, but the frequency is uninterrupted, right? So this is the example for the Epicon Megadyne. If you happen to have the Medtronic FT10, you can see similar things. Cut, if you're on pure cut, voltage is fairly low. And here they actually do use the term duty cycle on theirs, 100%. Coag, higher voltage with a duty cycle much lower. But if you see then, if you've ever wondered what blend means, well, you're right, it's just an in-between of the cut and coag, right? So it's moving the voltage more in the middle and the duty cycle is on. So you're gonna get a little bit of a mixed effect between those two. But then if you use the bipolar or the ligature sections, you see voltage is low, duty cycle is 100% or continuous. But some of you might, again, be robotic surgeons and now you're thinking, you're like, well, when I do the robot, I only have one choice. I have one button to activate my instrument and it's the blue one, which is traditionally the coag one. And so have no fear. It is not, you're not using the wrong waveform. It's just that on the robot, things are labeled a little bit differently. If you use the DaVinci XI, the electric circular generator that comes on that tower is the Irby Bio. And if we just jump down to the bipolar, you'll see that on cut, soft coag, soft coag, auto-stop, you are using an unmodulated current. So it is continuous. It's the same as like the cut unmodulated, okay? If on the XI, if you're using one of the advanced things like the synchro seal or a vessel sealer, you're gonna be, that comes from the E-100 generator. Same thing, frequency, it's continuous and the voltage is lower. It's relatively lower. And now if you do have the DV-5, which is the newest, the DaVinci V, they have integrated those two things. So it's no longer two separate generators, but it's now just one together. It's the E-200. And again, you see some monopolar cut is a duty cycle of 100. They do have a blend, but the monopolar coag is interrupted, so lower duty cycle. But they do have one thing, monopolar coag that's low, is actually a hundred percent duty cycle. So I think they're actually sneaking in a little cut one there, and that's probably just to help use that to get, again, that deeper tissue penetration. For bipolar, you see all of them are using a hundred percent duty cycle. And the advanced bipolar, whether you're using kind of the, whichever method, coagulation, sealer, sync, it's all a hundred percent. So don't worry on the robot. When you are using your bipolar, you are using a continuous uninterrupted waveform, which is the desired one to get good deep tissue effect. Now, just to step through a few, maybe just specific instruments you may run into. Sorry, this picture comes up a touch blurry, but the PK gyrus. We used to have this at our hospital. I don't see it around, so I'm not sure if other people are using it, but this is essentially a bipolar, but it's a pulsatile bipolar. Essentially when you activate this device, it just applies the energy, it just turns it on and off on its own. So if you actually watch how it operates as it's having its tissue effect and bubbles are forming, you'll see it kind of in a pulse fashion. The reason it does this is to try to minimize the thermal spread. You can do the same thing if you have like a reusable bipolar, or if like whether you're on a robot or a laparoscopic case, if you just simply step on and off the pedal, you'll see the same effect happening. And that is one way to minimize some of your thermal spread as you do that. One thing to note though, if you do use PK drivers, that actually it is a bipolar instrument, but it does actually allow you to choose continuous or interrupted current. So just advise you to choose wisely. Remember with bipolar, we should really always be using continuous, the traditionally called cut current. Ligature, this would be called an advanced bipolar. So what does that mean? This essentially means that the device is responding to the tissue as it administers energy. All right, so it is constantly measuring the resistance of the tissue, 4,000 Hertz, so 4,000 times a second, and it's modulating its power output to give the proper amount of power to desiccate the tissue appropriately. And this is one way that it helps to minimize thermal spread and also to ensure it's getting a nice deep penetration of the tissue, right? And again, the desiccation is the drying out. So right as it's going, you desiccate the tissue, the water is vaporizing, and thus when there's no water, that's where the resistance goes up. And that's how it measures when it's completely done and gives you the little tone that it's done. And then a real quick question, because I would get this a lot when I used to work on labor and delivery, the nurses, when we'd use a Ligature for self-injections, would try to make sure we had to put an extra pad on to hook up to the Ligature generator, because we use a different one. And I don't have to argue, but you do not need a dispersible electrode on a Ligature, because it's not monopolar, it's bipolar, right? Your electrodes are built into the device. But I'll give a quick disclaimer, unless you're using the Ligature, which does have a monopolar hook on it, then you are going to need a dispersive pad for that. Enseal is another advanced bipolar. The newest generation functions essentially similar to the Ligature in that it's measuring tissue feedback for resistance or desiccation and adjusting the power output to it. And then what I'll talk about is essentially ultrasonic energy, which two of the main ones that use purely ultrasonic are the Ethicon Harmonic and the Medtronic Sonocision. And then I'll ask this to some of my residents, and they say like, hey, is this a monopolar or a bipolar instrument? But it's a little bit of a trick question, because it's neither. The ultrasonic instruments are not sending an electrical current through the patient's tissues at all. It uses ultrasonic energy, which means that the one blade on this picture, specifically the small black blade that's parallel to the shaft of the instrument is going back and forth at ultrasonic frequency, so 55,000 times a second. And this simply creates mechanical energy that heats water in the cells, vaporizes cells, and you get your tissue effect that will lead to both hemostasis, some burning and cutting of tissue. You kind of get both at the same time. There are two different activation modes on many of the ultrasonic instruments. And essentially, it's still using the same frequency of blade motion, but the distance the blade is moving is different. And so, for example, just on this one, the harmonic, the green button on the side is for more hemostasis, so the blade will move a shorter distance. It will still cut the tissue, but you're getting more hemostasis. In this, again, you will not need a dispersive electrode because, again, you're not sending electrical current through the patient. And then just to call it one other instrument that is ultrasonic, the Olympus Thunderbeat does use ultrasonic, but it also has bipolar built into it just to maybe help control some bigger vessels that maybe may bleed. So just to kind of let you know where those fit into it. All right, so let's practice. Okay, so now I'm gonna stop sharing this and we're just gonna go to my main screen. So, all right. So I just want you to visualize that, I tried to make a urogyne applicable question here, but let's say you're doing a sacrococcal vaccine, you need to do a hysterectomy and you do a supracervical hysterectomy. Don't throw me off if I'm not using the right terms for the procedure here. But so you have the uterine corpus and you need to get that out. And whether you're doing this laparoscopically or robotically, now you have this, you know, uterus, got my little thing here, right? And you're suspending it up in the air between some of your laparoscopic instruments or graspers. And so we're gonna bring up a poll question here about to see what do you think are some safe ways that within the body cavity, you can kind of cut this uterine corpus into pieces? So we'll bring up this poll. So the question is, what is an acceptable and safe method to bivalve or cut into pieces a suspended uterine corpus during laparoscopic surgery? All right, and you can select multiple correct options if you feel there are multiple correct ones. So A, can you use your monopolar scissors, kind of cold without any radiofrequency energy? B, is monopolar scissors using the cut? C, the monopolar scissors using coag? D, a bipolar spatula? Or E, an ultrasonic scalpel? So he has a few moments to think. So again, just think you're like, you're holding the uterine corpus kind of in midair in an inflated belly. Which of these options can you use to safely cut that out? All right, let's bring up the results. Okay, so we had some good responses. So let's see, 67% said it would be okay to use the monopolar scissors cold. 17% said you could use the monopolar scissors on cut. 17% the monopolar scissors and coag. 67% said the bipolar spatula and 83% said the ultrasonic scalpel. So the correct options are that you can use the scissors but only on the cold or no electrical energy. Because this goes back to the beginning when I talked about the circuit, right? If you have a suspended uterus during laparoscopy and you try to apply monopolar energy to it, the monopolar energy is gonna try to make a circuit somewhere and get back to your dispersive electrode. And if that's up in the air, also in your electrical energy is gonna start going through your instruments. It's gonna spark across midair to your sidewall of your pelvis, to your bowel, to your bladder or something, right? So monopolar energy, radio frequency energy cannot be used on something that's not in continuity or physically touching something for the circuit, right? A bipolar spatula you could use because it's all contained within the instruments. The ultrasonic scalpel is also appropriate because again, you're not applying any actual electrosurgical current to the tissue. So that's just one thing I really try to highlight. I've seen some like not so good videos at conferences that people share where they see this complication. You can actually see sparks coming off the fibroid or uterine corpus towards the bowel and things if you're doing that. So make sure if you're doing that, you just use cold scissors, bipolar or ultrasonic. And then just to run through real quick, just some examples of maybe other times that electrosurgery has maybe not been used quite appropriately or we've kind of learned from it. When robotic surgery came out for hysterectomies, there was pretty high vaginal cuff dehiscence rates. You know, in this study, it was as high as 4%. And if you read the methods, they're doing the copotomy with monopolar coagulation current. This one was just a case series of two of them for cuff dehiscence after a robot TLH. Again, from the method section, it was monopolar scissors on coag mode. But then a few years later, this came out that showed 654 robotic assisted TLHs. And there's only three cases of cuff dehiscence, which was 0.4%. So now we had rates of dehiscence that were much more comparable to abdominal or vaginal surgery. In this method section, we see that the copotomy was made using monopolar scissors in the cut mode. And then this one showed a change in practice where a surgeon was doing robotic assisted TLH. And for the first 50 in the series, was using coag on the copotomy and had four cuff complications, so 8% rate, and then switched for the next 100 to a cutting current, also slightly reducing the power and had no cuff complications. And so again, this is, I think it's just an example that with a cutting current, right, if you're doing the non-contact, you're just getting separation of the tissue, but not that deep tissue effect. Because when we bring that vaginal cuff back together, we want it to be able to heal. It needs to still have some vascularity to it. And now this is definitely getting to a little dive of history since now for tubal sterilizations, mainly we're doing bilateral self-injectomies, but it was an option for some time to do just bipolar desiccation of the fallopian tubes. But original studies, like the CREST study, showed that there was a super high risk of unintended pregnancy after tubal sterilization with bipolar coagulation, 54 per 1,000 patients, so extremely high failure rate. But then later they did a sub-analysis and found that actually, that for those that had, or in this small study, 16 women who had coagulating waveform had incomplete desiccation of the tube, whereas 20 women who had cutting waveform had complete desiccation. So they showed that if you were using the proper type of energy that you would get appropriate desiccation. And again, this kind of goes back to the meat on the grill analogy, right? If you are desiccating someone's fallopian tubes to prevent pregnancy, you really want their fallopian tube to look more like that brisket, completely cooked all the way through, not like a steak that's just been charred on the outside and it's still raw in the middle. So this led to best practices that at least three centimeters of the tube was desiccated, you were using a continuous waveform, and you should be using an ammeter to listen to know that the current is completely done and that you have complete resistance. And then this is kind of just in the last piece here, and then we'll be done for some questions. The last piece of the electrical surgical generator we talked about is adjusting the power output. And this is where you can increase or decrease the amount of power. And I just bring this up because I think as you start to understand the electrical surgical energy a bit more, if you're not getting an effect, like a tissue effect, your first response shouldn't be just to like turn up the power, right? That there's something wrong with the power. Because if you start getting too high, you're gonna get unintended tissue effects, right? And so when we really go through troubleshooting, like now you really think, now you think about your circuit, right? And just walk all the way through the circuit in your mind, right? So are your cords plugged in? Or if there are cords plugged in, are they even the right cords for your instruments? Is your instrument put together properly? Or is there some breakdown in how you're, you know, grasp or, you know, is your monopolar pencil tip not all the way pushed in? Maybe you've done all this and you find like, well, maybe I just need to switch cords. These cords are getting old and broken. Maybe the cord's going bad. Is your foot pedal working properly? Is your foot pedal plugged into the right spot? You know, is there an alarm condition? So like if you're using monopolar, is the pad on the patient or do you look at the generator and you see the red alarm there and you need to get the pad back on? And then I kind of think you're really, your last thing should be that the power is too low and adjust that. So really try to think when tissue or when you're not getting the proper tissue effect that you want, really think through that whole process, think through the circuit and the power should be the last thing you look at changing. And that closes us up. So we'll open the time now for questions. I think Colin is going to do that. I'm going to stop sharing here, so. Yeah, thank you so much, Dr. Barron, for a great talk. Again, I didn't mention this at the beginning, but Dr. Barron was one of my attendings in residency and he did this talk for us when I was a second or third year resident and it was a great talk. So thanks again, Dr. Barron. So if anyone has any questions, they can put them in the chat. Otherwise, I actually wrote down a couple of questions during the presentation. So Dr. Barron, I actually had two questions. Number one, you had mentioned briefly the jewelry thing with the dispersive electrode. So does this dispersive electrode, it checks to see if it's going through that dispersive electrode and if it's not, like if it's going somewhere else, it will just shut off the current, is that correct? Yeah, and that's kind of like that isolated straight current feature that the generator should be able to detect if the current it's administering is not coming back to the generator. So like one way I know that too is like when I do some of these generators for these like practice lectures and things, we have to get a perfect view. You have to, you know, you saw me in the past things, we try to like use the monopoly pencil on an orange and we have to get the pad on there. But the generators do everything you can turn off for demo mode where it doesn't require that and it will just apply it and let the kind of electricity go anywhere. But when it's on normal safety mode for OR use, it's gonna make sure that that current is coming back to itself. And, you know, we always hear things like, oh, we need to make sure we get all the jewelry off the patient. But, you know, patients may have metal joints or other metal in their body. What prevents, is that just that same safety mode obviously prevents it from the electric current to go into the joints, but what prevents or what makes it so we can actually still do surgery? Because if it's coupling to something metal in their body, it's just gonna shut off because of the safety mode. How come that ever happens? Yeah, I think, so like, if you know someone has like an artificial hip or something like that, you would wanna choose the opposite side, right? So if you can keep your pad away from known metal in the body, you'd wanna do that. But as far as like, you know, jewelry, so external metal, one will depend on what you're using, right? If you're not planning on using monopolar energy, it's really actually not that much of a concern, right? If you're using bipolar, that current is just passing through that little bit of tissue between your two paddles because the electricity is always gonna take the easiest path. And in that case, the easiest path is just going between the two. It's not, you know, traveling up the patient's chest and up their neck, out their ear or something to their earring. And for ultrasonic, you're not doing electrical energy at all. As far as like metal implants within the body, right? Those are contained within it. So again, it's just not gonna, the electricity is gonna take the easiest path. And so it's not gonna go like out of its way to go through a metal joint or things, right? And so if we just make sure that the path from our instrument to the pad is free of any metal in between there, it's good, right? But if there is metal, right, you just want, that's where you have to be careful. Like why, you know, if they're saying bony prominences or things, almost thinking about like kind of like a pinch point, right, where all that current might be directed to a focal spot and you get that high current density again, which is what you really want to avoid because that's when you get the tissue effect or burning. But theoretically, if it coupled to a metal joint, the safety mode on your generator would kick in and it wouldn't supply any more current because it wouldn't be clean. Yeah, as long as that current's not going through the joint and back to your pad or something, yeah. True. And then in residency, I remember sometimes bipolar grasper wouldn't work and you would have us do something to make the bipolar work better. Can you kind of describe that? Yeah, so I'll bring up a grasper just to help people visualize and things. So in my OR, I use mostly an ultrasonic scalpel and then I use a reusable bipolar just to help seal like bigger vessels and things. But sometimes what'll happen if you take like a really small bite of tissue and it's just kind of in the end tips, essentially like nothing will happen to that tissue. And what you'll see if you pay attention is that essentially the back of the jaws, this grasper is not a great example of it, but they're in contact. So again, electricity is gonna take the easiest path. So it goes down and it's just going through the back of your paddles. It's not going through the tissue. So in those moments, what I typically have people do is if you're bipolar, this would be same as like on a robotic surgery or anything. If you just open the tips just the slightest amount while you're still activating it, eventually you'll bring the back of the jaws out of contact and then the tissue in between it is the only thing contacting. And it's gonna force that electrical current to go through the tissue instead. So yeah, if your bipolar is not working when you're grasping and it's a small bite, you just gotta like open the jaws a little bit until it works. Awesome. Well, I don't see any other further questions. So I think that is it. Thank you guys so much for joining us tonight. And thank you so much, Dr. Barron. It was a great talk and that's all I have. Yeah, thanks for having me, everybody. Have a good night. Have a good night, everyone.

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