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Surgical Endoscopy
Erschienen in: Surgical Endoscopy 9/2013

01.09.2013 | Review

Energetic soft-tissue treatment technologies: an overview of procedural fundamentals and safety factors

verfasst von: N. J. van de Berg, J. J. van den Dobbelsteen, F. W. Jansen, C. A. Grimbergen, J. Dankelman

Erschienen in: Surgical Endoscopy | Ausgabe 9/2013

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Abstract

Background

Energy administered during soft-tissue treatments may cauterize, coagulate, seal, or otherwise affect underlying structures. A general overview of the functionality, procedural outcomes, and associated risks of these treatments, however, is not yet generally available. In addition, literature is sometimes inconsistent with regards to terminology. Along with the rapid expansion of available energetic instruments, particularly in the field of endoscopic surgery, these factors may complicate the ability to step back, review available treatment options, and identify critical parameters for appropriate use.

Methods

Online databases of PubMed, Web of Science, and Google Scholar were used to collect literature on popular energetic treatments, such as electrosurgery, plasma surgery, ultrasonic surgery, and laser surgery. The main results include review and comparison studies on the working mechanisms, pathological outcomes, and procedural hazards.

Results

The tissue response to energetic treatments can be largely explained by known mechanical and thermal interactions. Application parameters, such as the interaction time and power density, were found to be of major influence. By breaking down treatments to this interaction level, it is possible to differentiate the available options and reveal their strengths and weaknesses. Exact measures of damage and alike quantifications of interaction are, although valuable to the surgeon, often either simply unknown due to the high impact of tissue and application-dependent parameters or badly documented in previous studies. In addition, inconsistencies in literature regarding the terminology of used techniques were observed and discussed. They may complicate the formulation of cause and effect relations and lead to misconceptions regarding the treatment performance.

Conclusions

Some basic knowledge on used energetic treatments and settings and a proper use of terminology may enhance the practitioner’s insight in allowable actions to take, improve the interpretation and diagnosis of histological and mechanical tissue changes, and decrease the probability of iatrogenic mishaps.
Literatur
1.
Massarweh NN, Cosgriff N, Slakey DP (2006) Electrosurgery: history, principles, and current and future uses. J Am Coll Surg 202:520–530PubMedCrossRef
2.
Glover JL, Bendick PJ, Link WJ (1978) The use of thermal knives in surgery: electrosurgery, lasers, plasma scalpel. Curr Probl Surg 15:1–78PubMedCrossRef
3.
4.
Giombini A, Giovannini V, Di Cesare A, Pacetti P, Ichinoseki-Sekine N, Shiraishi M, Naito H, Maffulli N (2007) Hyperthermia induced by microwave diathermy in the management of muscle and tendon injuries. Br Med Bull 83:379–396PubMedCrossRef
5.
Calvo B, Pena E, Martinez MA, Doblare M (2007) An uncoupled directional damage model for fibred biological soft tissues. Formulation and computational aspects. Int J Numer Method Eng 69:2036–2057CrossRef
6.
Rodriguez JF, Cacho F, Bea JA, Doblare M (2006) A stochastic-structurally based three dimensional finite-strain damage model for fibrous soft tissue. J Mech Phys Solids 54:864–886CrossRef
7.
Brill AI (2008) Bipolar electrosurgery: convention and innovation. Clin Obstet Gynecol 51:153–158PubMedCrossRef
8.
Willson PD, Mills T, Williams NS, Rogers J (1995) Electrosurgical safety during laparoscopic surgery. Minim Invasive Ther 4:195–201CrossRef
9.
Amaral JF, Chrostek CA (1997) Experimental comparison of the ultrasonically-activated scalpel to electrosurgery and laser surgery for laparoscopic use. Minim Invasive Ther Allied Technol 6:324–331CrossRef
10.
Aksan A, McGrath JJ, Nielubowicz DS Jr (2005) Thermal damage prediction for collagenous tissues part I: a clinically relevant numerical simulation incorporating heating rate dependent denaturation. J Biomech Eng 127:85–97PubMedCrossRef
11.
Stylianopoulos T, Aksan A, Barocas VH (2008) A structural, kinetic model of soft tissue thermomechanics. Biophys J 94:717–725PubMedCrossRef
12.
Aksan A, McGrath JJ (2002) Effects of thermal damage on the mechanical properties of collagenous tissues. Tech Health Care 10:3
13.
Fung YC (1993) Biomechanics: mechanical properties of living tissues, 2nd edn. Springer, Berlin
14.
Malyshev A, Bityurin N (2004) Laser swelling of soft biological tissue by IR pulses. Appl Phys 79:1175–1179
15.
McKenzie AL (1989) Theoretical limits to soft-tissue damage by Er:YAG and Ho:YAG lasers. Lasers Med Sci 4:6CrossRef
16.
Palanker DV, Vankov A, Huie P (2008) Electrosurgery with cellular precision. IEEE Trans Biomed Eng 55:838–841PubMedCrossRef
17.
Emam TA, Cuschieri A (2003) How safe is high-power ultrasonic dissection? Ann Surg 237:186–191PubMed
18.
Tulikangas PK, Smith T, Falcone T, Boparai N, Walters MD (2001) Gross and histologic characteristics of laparoscopic injuries with four different energy sources. Fertil Steril 75:806–810PubMedCrossRef
19.
Phillips CK, Hruby GW, Durak E, Lehman DS, Humphrey PA, Mansukhani MM, Landman J (2008) Tissue response to surgical energy devices. Urology 71:744–748PubMedCrossRef
20.
Ryan RW, Wolf T, Spetzler RF, Coons SW, Fink Y, Preul MC (2010) Application of a flexible CO2 laser fiber for neurosurgery: laser-tissue interactions laboratory investigation. J Neurosurg 112:434–443PubMedCrossRef
21.
Hruby GI, Marruffo F, Durak E, Collins SM, Pierorazio PM, Humphrey PA, Mansukhani MM, Landman J (2007) Evaluation of surgical energy-devices for vessel sealing and peripheral energy spread in a porcine model: Harmonic ace, harmonic lcs-c5 ligasure 5, and trisector. J Urol 177:318
22.
Harold KL, Pollinger H, Matthews BD, Kercher KW, Sing RF, Heniford BT (2003) Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc 17:1228–1230PubMedCrossRef
23.
Carbonell AM, Joels CS, Kercher KW, Matthews BD, Sing RF, Heniford BT (2003) A comparison of laparoscopic bipolar vessel sealing devices in the hemostasis of small-, medium-, and large-sized arteries. J Laparoendosc Adv A 13:377–380CrossRef
24.
Goldstein SL, Harold KL, Lentzner A, Matthews BD, Kercher KW, Sing RF, Pratt B, Lipford EH, Heniford BT (2002) Comparison of thermal spread after ureteral ligation with the Laparo-Sonic ultrasonic shears and the Ligasure system. J Laparoendosc Adv Surg Tech A 12:61–63PubMedCrossRef
25.
Sibbons PD, Southgate A (2006) Comparison of wound-healing and tissue effects using the Gyrus Plasmaknife with monopolar, Coblation, and Harmonic Scalpel methodologies. Comp Clin Pathol 15:10CrossRef
26.
Mantke R, Halangk W, Habermann A, Peters B, Konrad S, Guenther M, Lippert H (2011) Efficacy and safety of 5-mm-diameter bipolar and ultrasonic shears for cutting carotid arteries of the hybrid pig. Surg Endosc 25:577–585PubMedCrossRef
27.
Huscher CG, Lirici MM, Di Paola M, Crafa F, Napolitano C, Mereu A, Recher A, Corradi A, Amini M (2003) Laparoscopic cholecystectomy by ultrasonic dissection without cystic duct and artery ligature. Surg Endosc 17:442–451PubMedCrossRef
28.
Krane C, Pinnell M, Gardner C, Thompson M, Coleman J, Wilkens R (2011) Mechanical test methods for assessing porcine carotid and uterine artery burst pressure following ex vivo ultrasonic ligature seal and transection. J Test Eval 39:514–521
29.
Sindram D, Martin K, Meadows JP, Prabhu AS, Heath JJ, McKillop IH, Iannitti DA (2011) Collagen-elastin ratio predicts burst pressure of arterial seals created using a bipolar vessel sealing device in a porcine model. Surg Endosc 25:2604–2612PubMedCrossRef
30.
Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A (2006) Surgical smoke and infection control. J Hosp Infect 62:1–5PubMedCrossRef
31.
de Boorder T, Verdaasdonk R, Klaessens J (2007) The visualisation of surgical smoke produced by energy delivery devices: significance and effectiveness of evacuation systems—art. no. 64400R. Therm Treat Tissue Energy Deliv Assess IV 6440:R4400
32.
Ulmer BC (2008) The hazards of surgical smoke. AORN J 87:721–734; quiz 735-728
33.
Gatti JE, Bryant CJ, Noone RB, Murphy JB (1992) The mutagenicity of electrocautery smoke. Plast Reconstr Surg 89:781–784 discussion 785-786PubMedCrossRef
34.
Bigony L (2007) Risks associated with exposure to surgical smoke plume: a review of the literature. AORN J 86:1013–1020 quiz 1021-1014PubMedCrossRef
35.
Krones CJ, Conze J, Hoelzl F, Stumpf M, Klinge U, Möller M, Dott W, Schumpelick V, Hollender J (2007) Chemical composition of surgical smoke produced by electrocautery, harmonic scalpel and argon beaming—a short study. Eur Surg 39:4CrossRef
36.
37.
Barrett WL, Garber SM (2002) Surgical smoke: a review of the literature. Is this just a lot of hot air? Surg Endosc 17:9
38.
Elliott JA Jr (1966) Electrosurgery. Its use in dermatology, with a review of its development and technologic aspects. Arch Dermatol 94:340–350PubMedCrossRef
39.
40.
Ward AK, Ladtkow CM, Collins GJ (2007) Material removal mechanisms in monopolar electrosurgery. Conf Proc IEEE Eng Med Biol Soc 2007:1180–1183PubMed
41.
Wu MP, Ou CS, Chen SL, Yen EYT, Rowbotham R (2000) Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg 179:67–73PubMedCrossRef
42.
43.
Den Boer KT, Straatsburg IH, Schellinger AV, De Wit LT, Dankelman J, Gouma DJ (1999) Quantitative analysis of the functionality and efficiency of three surgical dissection techniques: a time-motion analysis. J Laparoendosc Adv A 9:389–395CrossRef
44.
45.
Riegler M, Cosentini E, Bischof G (2004) Review: update and economic aspects of the harmonic scalpel in general surgery. Eur Surg 36:8CrossRef
46.
Montero PN, Robinson TN, Weaver JS, Stiegmann GV (2010) Insulation failure in laparoscopic instruments. Surg Endosc 24:462–465PubMedCrossRef
47.
Voyles CR, Tucker RD (1992) Education and engineering solutions for potential problems with laparoscopic monopolar electrosurgery. Am J Surg 164:57–62PubMedCrossRef
48.
Vilos G, Latendresse K, Gan BS (2001) Electrophysical properties of electrosurgery and capacitive induced current. Am J Surg 182:222–225PubMedCrossRef
49.
Abu-Rafea B, Vilos GA, Al-Obeed O, AlSheikh A, Vilos AG, Al-Mandeel H (2011) Monopolar electrosurgery through single-port laparoscopy: a potential hidden hazard for bowel burns. J Minim Invasive Gynecol 18:734–740PubMedCrossRef
50.
Ramsay JW, Shepherd NA, Butler M, Gosling PT, Miller RA, Wallace DM, Whitfield HN (1985) A comparison of bipolar and monopolar diathermy probes in experimental animals. Urol Res 13:99–102PubMedCrossRef
51.
Kong MG, Kroesen G, Morfill G, Nosenko T, Shimizu T, van Dijk J, Zimmermann JL (2009) Plasma medicine: an introductory review. N J Phys 11:115012CrossRef
52.
Palanker DV, Miller JM, Marmor MF, Sanislo SR, Huie P, Blumenkranz MS (2001) Pulsed electron avalanche knife (PEAK) for intraocular surgery. Invest Ophthalmol Vis Sci 42:2673–2678PubMed
53.
ArthroCare (2008) COBLATION Technology. Online
54.
Lloyd G, Friedman G, Jafri S, Schultz G, Fridman A, Harding K (2010) Gas plasma: medical uses and developments in wound care. Plasma Proc Polym 7:194–211CrossRef
55.
Sakiyama Y, Graves DB (2006) Corona-glow transition in the atmospheric pressure RF-excited plasma needle. J Phys D Appl Phys 39:3644–3652CrossRef
56.
Sakiyama Y, Graves DB, Stoffels E (2008) Influence of electrical properties of treated surface on RF-excited plasma needle at atmospheric pressure. J Phys D Appl Phys 41:095204CrossRef
57.
Miller JM, Palanker DV, Vankov A, Marmor MF, Blumenkranz MS (2003) Precision and safety of the pulsed electron avalanche knife in vitreoretinal surgery. Arch Ophthalmol 121:871–877PubMedCrossRef
58.
Mowatt G, Cook JA, Fraser C, McKerrow WS, Burr JM (2006) Systematic review of the safety of electrosurgery for tonsillectomy. Clin Otolaryngol 31:95–102PubMedCrossRef
59.
Palanker D, Vankov A, Miller J, Friedman M, Strauss M (2003) Prevention of tissue damage by water jet during cavitation. J Appl Phys 94:2654–2661CrossRef
60.
Priglinger SG, Haritoglou C, Mueller A, Grueterich M, Strauss RW, Alge CS, Gandorfer A, Palanker D, Kampik A (2005) Pulsed electron avalanche knife in vitreoretinal surgery. Retina 25:889–896PubMedCrossRef
61.
Loh SA, Carlson GA, Chang EI, Huang E, Palanker D, Gurtner GC (2009) Comparative healing of surgical incisions created by the PEAK PlasmaBlade, conventional electrosurgery, and a scalpel. Plast Reconstr Surg 124:1849–1859PubMedCrossRef
62.
Gossot D, Buess G, Cuschieri A, Leporte E, Lirici M, Marvik R, Meijer D, Melzer A, Schurr MO (1999) Ultrasonic dissection for endoscopic surgery. The E.A.E.S Technology Group. Surg Endosc 13:412–417PubMedCrossRef
63.
Heili MJ, Flowers SA, Fowler DL (1999) Laparoscopic-assisted colectomy: a comparison of dissection techniques. JSLS 3:27–31PubMed
64.
Koch C, Friedrich T, Metternich F, Tannapfel A, Reimann HP, Eichfeld U (2003) Determination of temperature elevation in tissue during the application of the harmonic scalpel. Ultrasound Med Biol 29:301–309PubMedCrossRef
65.
66.
Karvounaris DC, Antonopoulos V, Psarras K, Sakadamis A (2006) Efficacy and safety of ultrasonically activated shears in thyroid surgery. Head Neck 28:1028–1031PubMedCrossRef
67.
Kim FJ, Chammas MF Jr, Gewehr E, Morihisa M, Caldas F, Hayacibara E, Baptistussi M, Meyer F, Martins AC (2008) Temperature safety profile of laparoscopic devices: Harmonic ACE (ACE), Ligasure V (LV), and plasma trisector (PT). Surg Endosc 22:1464–1469PubMedCrossRef
68.
Sutton PA, Awad S, Perkins AC, Lobo DN (2010) Comparison of lateral thermal spread using monopolar and bipolar diathermy, the Harmonic Scalpel and the Ligasure. Br J Surg 97:428–433PubMedCrossRef
69.
Pogorelic Z, Perko Z, Druzijanic N, Tomic S, Mrklic I (2009) How to prevent lateral thermal damage to tissue using the harmonic scalpel: experimental study on pig small intestine and abdominal wall. Eur Surg Res 43:235–240PubMedCrossRef
70.
McCarus SD (1996) Physiologic mechanism of the ultrasonically activated scalpel. J Am Assoc Gynecol Laparosc 3:601–608PubMedCrossRef
71.
Amaral JF, Chrostek C (1995) Depth of thermal injury: ultrasonically activated scalpel vs electrosurgery. Surg Endosc 9:1
72.
ten Broek RP, Wilbers J, van Goor H (2011) Electrocautery causes more ischemic peritoneal tissue damage than ultrasonic dissection. Surg Endosc Interv Tech 25:1827–1834CrossRef
73.
74.
Welch AJ (1984) The thermal response of laser irradiated tissue. IEEE J Quantum Elect 20:1471–1481CrossRef
75.
Muller G, Schaldach B (1989) Basic laser tissue interaction. Lasers Med Sci 4:9
76.
Teichmann HO, Herrmann TR, Bach T (2007) Technical aspects of lasers in urology. World J Urol 25:221–225PubMedCrossRef
77.
Boulnois JL (1986) Photophysical processes in recent medical laser developments: a review. Lasers Med Sci 1:47–66CrossRef
78.
Welch AJ, Torres JH, Cheong WF (1989) Laser physics and laser-tissue interaction. Tex Heart I J 16:141–149
79.
Burns JA, Kobler JB, Heaton JT, Lopez-Guerra G, Anderson RR, Zeitels SM (2007) Thermal damage during thulium laser dissection of laryngeal soft tissue is reduced with air cooling: ex vivo calf model study. Ann Otol Rhinol Laryngol 116:853–857PubMed
80.
Kim AH, Adamson GD (1999) Chapter 4: Laparoscopic laser injury. Prevention and management of laparoendoscopic surgical complications, Society of Laparoendoscopic Surgeons
81.
Lin WC, Motamedi M, Welch AJ (1996) Dynamics of tissue optics during laser heating of turbid media. Appl Opt 35:3413–3420PubMedCrossRef
82.
Sawchuk WS, Weber PJ, Lowy DR, Dzubow LM (1989) Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol 21:41–49PubMedCrossRef
83.
Robinson TN, Pavlovsky KR, Looney H, Stiegmann GV, McGreevy FT (2010) Surgeon-controlled factors that reduce monopolar electrosurgery capacitive coupling during laparoscopy. Surg Laparosc Endosc Percutan Tech 20:317–320PubMedCrossRef
84.
Ching SS, McMahon MJ (2007) Comparison of linear and torsional mode ultrasonic coagulating shears for the sealing of medium- to large-sized arteries. Surg Endosc 21:1165–1169PubMedCrossRef
85.
Newcomb WL, Hope WW, Schmelzer TM, Heath JJ, Norton HJ, Lincourt A, Heniford BT, Iannitti DA (2009) Comparison of blood vessel sealing among new electrosurgical and ultrasonic devices. Surg Endosc 23:90–96PubMedCrossRef
86.
Schlee M, Steigmann M, Bratu E, Garg AK (2006) Piezosurgery: basics and possibilities. Implant Dent 15:334–340PubMedCrossRef
87.
Clements RH, Palepu R (2007) In vivo comparison of the coagulation capability of SonoSurg and Harmonic Ace on 4 mm and 5 mm arteries. Surg Endosc 21:2203–2206PubMedCrossRef
Metadaten
Titel
Energetic soft-tissue treatment technologies: an overview of procedural fundamentals and safety factors
verfasst von
N. J. van de Berg
J. J. van den Dobbelsteen
F. W. Jansen
C. A. Grimbergen
J. Dankelman
Publikationsdatum
01.09.2013
Verlag
Springer US
Erschienen in
Surgical Endoscopy / Ausgabe 9/2013
Print ISSN: 0930-2794
Elektronische ISSN: 1432-2218
DOI
https://doi.org/10.1007/s00464-013-2923-6

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