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Dr Sami ElBoghdadly Assistant Professor of surgery Consultant Surgeon Director of OR and Day Surgery King Abdulaziz Medical City, Riyadh, KSA

Goethe 17491832

When Knowledge is not enough ..........Till we apply it When willingness is not enough ............Till we execute it

History of Electrosurgery "...Heat relieves these diseases." -Hippocrates

Electrosurgery

The application of high frequency electric Current to biological tissue as a means to cut, coagulate, desiccate or fulgurate tissues. Electro surgery works by producing HEAT

Electrosurgical Tissue Endpoints

· Three primary tissue phenomena achievable with electrosurgery: vaporization, fulguration, and coagulation · Further differentiated as being "contact" or "non-contact"

Basic Principles of Electrosurgery

Current conducted through a complete circuit including the generator, insulated cables, electrodes, and the patient

Copyright 2007

Electrosurgical Waveforms: Cut, Blend & Coag

· Alternating current used for electrosurgery is a sinusoidal waveform, constantly changing directions · Waveforms produced by an ESU range from the continuous low-voltage cut output to the discontinuous high-voltage coag output, providing outputs of varying current and voltage · Cut, blend, and coag does not refer to literal tissue effects

Dual Plate Return Electrodes

Interrogation current flows between each plate of the electrode and the patient. If one side is partially detached from the patient, an alarm will sound.

Copyright 2007

Reducing Risk During Conventional and Laparoscopic Electrosurgery: Electrosurgical Burns

Fundamentals & Biophysics of Electricity

Frequency Spectrum: Electrosurgery utilizes high frequency alternating current in the radiofrequency range.

Bipolar & Monopolar Electrosurgery

Bipolar Electrosurgery

All electrosurgery is intrinsically bipolar due to the use of alternating current.

Advanced bipolar

Provides a combination of pressure and energy to create vessel fusion Permanently fuses vessels up to and including 7 mm in diameter and tissue bundles without dissection or isolation Average seal cycle is 2 to 4 seconds* Seals withstand three times normal systolic blood pressure Feedbackcontrolled response system automatically discontinues energy delivery when the seal cycle is complete, eliminating the guesswork

Advanced Bipolar

·Measuring the impedance will stop it automatically ·Good for sealing vessels but need a cutting device ·Bulky for laparoscopic surgery ·Smoke.

Advanced Bipolar Technology

Advanced Bipolar Technology controls 3 important factors for vessel sealing. Collagen ·Not too low nor high TEMPERATURE for mobilization Lumen Advanced Bipolar ·A certain TIME for mobilization ·Sufficient PRESSURE for fusing vessel walls

Collagen molecules constitutes triple spiral

Mobilization

Recombination (partial)

Heating

Cooling.

Ultrasonic Devices

Vibrating in the range 55KHz. It Cuts and Seals simultaneously It works by Protein Denaturization. Still heat producing devices. It rather cuts than seal.

Ultrasonic Energy Technology

Why ultrasonic energy devices have a limited vessel sealing capability? REMEMBER, what are the 3 important factors for successful vessel sealing?

<Pressure>

Temp. Time Pressure

?

Tend to be insufficient as the probe needs to keep vibrating.

<Temperature and Time>

Heat distribution is uneven.

With Advanced Bipolar and Ultrasound devices who needs more?

Current Technologies

Sealing capability

Advanced bipolar

?

Vessel Sealing Conventional bipolar

Cutting capability

?

Coagulation

Current Technologies

Sealing capability

Advanced bipolar

?

Vessel Sealing

Conventional bipolar

Ultrasonic

Cutting capability

Coagulation

Synergistic Energy

platform with ordinary Electrosurgical capabilities · A combined Advanced Bipolar and Ultrasonic device · Capabilities of Advanced bipolar · Minimal Mist · Can be used for open · And laparoscopic procedure

·A

Synergistic Energy

What is it?

Synergistic Energy

Advanced Bipolar Technology in Synergistic Energy

Advanced Bipolar technology controls 3 important factors for sealing. <Pressure>

Temp. Time Pressure

Improved instrumentation for sufficient pressure on the tissue. <Temperature & Time> Controlled energy delivery by dedicated algorithm for sealing.

250.0

Temp ()

200.0 150.0 100.0 50.0 0.0 0

(sec) Time (sec) 1 2 3 4

Jaw

upper

Controlled!!

middle Temp. / Time

Jaw lower

Performance of Synergistic Energy Platform

Cutting Speed ­ Mesentery (5 cm)

Comp A

Comp B

Comp C

In Vitro Cutting Performance

TBeat 24% faster TBeat 40.8% faster TBeat 101.4% faster

Comp B

Comp C

Comp A

Mesentery: Cutting through 20cm porcine mesentery

Vessel Sealing Performance Large Vessels

ThunderBeat : 57% greater ThunderBeat: 53% greater

Comp A

Comp C

Vessel Size: Large (4.0< X 7.0)

FDA Submission Test Report A, pp 10-12

Maximum Instrument Temperature Seal

Comp A Comp B

Activation stopped immediately when sealing completion is notified.

FDA Submission Test Report IJ, p. 6-10

Thermal Spread

Comp A Comp B Comp C

Measured Histologically

Tip Grasping Force

Comp B

Comp A*

Comp C*

* Due to jaw design, Competitor products A and C were unable to exert any

grasping force at the tip of the device.

FDA Submission Test Report K, p. 7-16

Fine and Easy Dissection

Highest grasping force at the tip, allowing easier catch of fine tissue

1mm 3mm

Grasping a 0.05mm thickness poly-ethylene sheet at different tip lengths.

Comp B

Comp A

Comp C

* Due to jaw design, Competitors A and C were unable to exert any grasping force at

the tip of the device.

Fine and Easy Dissection

Finest tip for easier entry into tissue planes

Comp A

Comp C

Comp B

a

Mist Evaluation

THUNDERBEAT: 89% less light attenuation

THUNDERBEAT: 93% less light attenuation

Comp B

FDA Submission Test Report K, p. 9

Maximum Instrument Temperature

Comp B

Condition A: Activation stopped immediately when cutting is completed. Condition B: Activation stopped 1 second after cutting is completed.

FDA Submission Test Report IJ, p. 6-10

Synergistic Energy clinical experience

4 active centres in UK (@ 16 December 2011) @ end of October in Continental Europe: Marseille, Hospital Nord, Prof. Berdah Stockholm, Ersta Hospital, Dr. Carlens Odense, Univ. Hospital, Dr. Poornoroozy Vienna, Floridsdorf, Dr. Razek/Prof. Tuchmann Leewarden, Medical Center, Dr. Hoff Rotterdam, Erasmus. Dr. Geert Kazemier Alessandria, Italy, Prof. Spinoglio Hamburg, Altona Hos., Prof. Schwenk Baden CH, Prof. Kocher Gent, Univ, Prof. van Niweuwenhove/Prof. Pattyn

Clinical Experience

Early experience: 3 Laparoscopic Sigmoid and low anterior resection one open: Omentectomy, Bilateral oophrectomy, Right hemicolectomy No blood transfusion Safe Very short learning curve Speedy dissection Versatility Quick

Denial

commitment

Rejection

Acceptance

Conclusions:

· New Horizon in the Energy platform · Advanced Synergistic Energy platform of combined Advanced Bipolar and Ultrasonic energies is a class on its Owen ·Early clinical experience exceeded expectations. ·More clinical experience needed to explore its all potentials

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