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Hysteroscopie : Mono- en bipolaire energie

Hysteroscopie : Mono- en bipolaire energie. Dr. M. Francx ZNA Campus Middelheim. Principes bij gebruik. A. Inleidende begrippen electrochirurgie fysische begrippen monopolaire electrochirurgie begrippen : 1. cutting = electrosectie = vaporisatie 2. coagulatie = desicatie

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Hysteroscopie : Mono- en bipolaire energie

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  1. Hysteroscopie : Mono- en bipolaire energie Dr. M. Francx ZNA Campus Middelheim

  2. Principes bij gebruik A. Inleidende begrippen electrochirurgie • fysische begrippen • monopolaire electrochirurgie begrippen : 1. cutting = electrosectie = vaporisatie 2. coagulatie = desicatie 3. Bipolaire electrochirurgie Principes Werking B. Versapoint 1. werking 2. electroden 1)Dunne bipolaire electroden • Typen • Indicatie • voordelen 2) Brede bipolaire electroden

  3. Fundamentals of Electrosurgery • 3.Pijnstilling • 4. Gebruiksregels • 5. Indicaties • Myomectomie • Endometriumablatie • Adhesiolysis (Asherman) • Poliepectomie • Septumresectie • 6. Voor- en nadelen

  4. Fundamentals of Electrosurgery • Ohm’s Law • V = I x R • V= Voltage • I= Current • R = Resistance or impedance

  5. Fundamentals of Electrosurgery • What Is Voltage? • Electromotive force that drives current through a circuit (tissue) • Voltage is Force

  6. Fundamentals of Electrosurgery • What Is Electrosurgery? • Application of high frequency alternating current (AC) • Creatingsecondarythermal tissue effects

  7. Fundamentals of Electrosurgery Electrosurgery Utilizes Alternating Current (AC) • Typical electrosurgical generators work at 500,000 - 3,000,000 hertz (cycles per second) • Frequency range needed to prevent neuromuscular stimulation – the so-called Faradic effects

  8. Fundamentals of Electrosurgery • Technical implications of increasing voltage • More bubbles from hydrogen gas formation • Carbonization and darkening of tissue • Adherence • Less margin for error near viscera and vessels

  9. Monopolar Electrosurgery

  10. Monopolar Electrosurgery • What Is Monopolar Electrosurgery? • High density current enters tissue from small active electrode creating secondary thermal events • Current flows through the patient via a myriad of conductive pathways and volume conduction • Current dispersed over a large surface return electrode • Current returns to isolated ground housed in the electrosurgical generator

  11. Monopolar Electrosurgery Tissue Effects of Electrosurgery: Cutting = Vaporization Electrosection Coagulation = Desiccation

  12. Monopolar Electrosurgery Monopolar Electrosurgery in a Fluid Environment • Electrolyte-containing distention media are effective conductors • Act to enlarge surface area of active electrode • Dramatically reduce the current density • Rendering electrosurgical effect ineffectual • Non-conductive distention media are effective insulators • Glycine, sorbitol, mannitol • Current density is maintained, electrosurgical effect unaltered • Desiccation, cutting, vaporization, fulguration all available

  13. Monopolar Electrosurgery RUNNING CURRENT Active Electrode Generator TISSUE (mass) Return Electrode

  14. Monopolar Electrosurgery Minimizing Risk With Return Electrode Pads Burn = Heat x Time/Surface Area

  15. Bipolar Electrosurgery Monopolar “Active” Electrode “Return” Electrode • cutting, coagulation • High voltages (< 9000V) • Deep necrosis, coagulation margins

  16. Fundamentals of Electrosurgery • Monopolair • electrolietenarm milieu -> gevaar fluid-overload (TURP-syndroom) • ‘voorbijgestreefd’ (?) • gevaar brandwonden (op afstand) • cutting + coagulatie • Bipolair • fysiologisch water -> gevaar fluid-overload beperkt • ‘actueel’ • energiestromen beperkt (gevaar brandwondenbeperkt) • cutting + coagulatie

  17. Bipolar Bipolar “Return” “Active” Electrode Electrode “Active” Electrode Desiccation • Desiccation • Local effect • Local effect • Low power and voltages • Low power and voltages Bipolar Electrosurgery Bipolar Electrosurgery

  18. VersaPoint Bipolar VersaPoint Bipolar Bipolar Bipolar Normal saline “Return” “Return” “ Active ” Electrode Electrode Electrode “ Active ” Electrode “ Active ” Electrode Vaporisation , desiccation , • Vaporisation , desiccation , cutting cutting Desiccation • Desiccation controled margins • controled margins • • Local effect • Local effect averaged power and voltages • averaged power and voltages • • Low power and voltages • Low power and voltages Bipolar Electrosurgery

  19. Bipolar Electrosurgery What Is Bipolar Electrosurgery? • Consolidation of active and return electrodes into single instrument • Current is symmetrically distributed through the tissue between the two electrodes • Patient is not part of essential current pathway • Thermal damage is limited to discrete volume of tissue • Power requirements are reduced with higher electrosurgical efficiency

  20. Bipolar Electrosurgery Mechanism of Desiccation

  21. Bipolar Electrosurgery VersaPoint Bipolar VersaPoint Bipolar Normal saline “Return” Electrode “Active” Electrode Vaporisation, desiccation, • Vaporisation, desiccation, cutting cutting • controled margins • controled margins • averaged power and voltages • averaged power and voltages

  22. VersaPoint Bipolar VersaPoint Bipolar Monopolar Bipolar Monopolar Bipolar Normal saline “Return” “Return” “Active” Electrode Electrode Electrode “Active” “Active” Electrode Electrode “Active” “Return” Electrode Electrode Vaporisation, desiccation, • Vaporisation, desiccation, • cutting, coagulation • cutting, coagulation cutting cutting • High voltages ( < 9000V) • High voltages ( < 9000V) Desiccation • Desiccation • controled margins • controled margins • Deep necrosis, • Deep necrosis, • Local effect • Local effect coagulation coagulation • averaged power and voltages • averaged power and voltages • Low power and voltages • Low power and voltages margins margins Bipolar Electrosurgery

  23. Bipolar Electrosurgery Tissue Effect Control

  24. Bipolar Electrosurgery System for Bipolar Hysteroscopic Surgery • 1.6 mm (5 F) in diameter • Two poles separated 2 mm at distal shaft by ceramic insulator • Electrodes designed for variable tissue effects • Ball tip= precise vaporization and desiccation • Spring tip = rapid tissue vaporization and desiccation • Twizzle tip= vaporization and needle-like cutting • Given small size and focused tissue effects, best for • polypectomy, adhesiolysis, vaporization of smallersubmucous myomata

  25. Bipolar Electrosurgery • Electroden • Dunne bipolaire electroden • = 5F= 1,6 mm • werken statisch : electrode + scoop bewegen samen • Veer : vooral vaporisatie • Staafje : fijne cutting + coagulatie • Bolletje : coagulatie • Brede bipolaire electroden • = 24 F = 8 mm breed - 2 of nu 4mm hoog • werken passief : alleen de electrode beweegt zonder scoop • Bipolaire loop : 45° of 90° • cutting + coagulatie • Gegroefde electrode : 0° • cutting + coagulatie

  26. Bipolar Electrosurgery • INDICATIE operatieve hysteroscopie • - Ambulant : bipolaire kleine electroden • kleine tot middelgrote poliepen • kleine synechieën • kleine myomata type 0/1 (<2cm) • septum • Rachi/alg.anesthesie: loop of razor • . Grote poliepen • . Grotere Myomata type 0/1/2 • . Endometriumresectie • . Asherman

  27. Bipolar Electrosurgery:Ambulante Hyst • No dilatation • No general anaesthesie • Less risks for perforation • Less risks for laceration of the cervix • No risk for sorbitol overload • No risk for burn injuries

  28. Bipolar Electrosurgery Resectoscopic SystemBipolar Vaporization and Desiccation • Requires dedicated 27 F resectoscope • Mimics tissue effect of monopolar grooved electrodes • Bipolar electrode configuration • Proximal stainless steel passive electrode • Ceramic alloy insulator • Distal 4 mm (24 F) fixed grooved stainless steel active electrode

  29. Bipolar Electrosurgery Bipolar Loop Electrode

  30. Operative Hysteroscopy • Alg. of locoreg. Anesth. • Myomectomy • Polypectomy • Synechiolysis • Septum resection • Endometrial ablation

  31. Bipolar Electrosurgery • Pijnstilling • A. Gebruik kleine electroden: • Ofwel : • 1 tablet cytotech in de vagina de avond voor de ingreep en 1 tablet voor de ingreep. • Dit is een prostaglandinepreparaat dat gegeven wordt om de cervix te verweken en het instrumentarium gemakkelijker door de cervix te laten gaan. Een uur voor de ingreep geeft men een Brufen Forte of Voltaren. Deze kan later herhaald worden voor pijnstilling. • Ofwel : • 30’ voor ingreep : 1 suppo Indocid 100 mg of Brufen Fort. • 0,25 mg Atropine I M • na ingreep : direct erna : 1 Cataflam • na drie uur: 1 Cataflam

  32. Bipolar Electrosurgery • Pijnstilling • B. Gebruik grote electroden: • Algemene anesthesie of peridurale of 2 ...

  33. Bipolar Electrosurgery • Pijnstilling • B. Gebruik grote electroden: • Algemene anesthesie, peridurale of rachi

  34. Bipolar Electrosurgery • Gebruiksregels • De electrode nooit activeren bij dieper inbrengen • De electrode niet activeren bij onduidelijk zicht • Gebruik de minst noodzakelijke power • Gebruik de laagste voltage • Respecteer de positie van de camera • Let op de oppervlakkige vascularisatie en • dunheid van het endometrium h.v. de isthmus • Werk met ervaren personeel • Neem een biopsie vóór de vaporisatie • Doe een correctie vochtmonitorring met gebruik • van een pomp zelfs bij gebruik van NaCl.

  35. Operative Hysteroscopy Intrauterine Lesions : - Polyps and myomas- Theyt don’t go away in menopauze !

  36. Operative Hysteroscopy Submucous Myoma Classification Type Intramural Extension 0 None I <50% II >50%

  37. Bipolar Electrosurgery • Mogelijke verwikkelingen bij hysteroscopie • Perforatie • Bloeding • Infectie • Thermaal letsel • Vochtoverlading • Hyponatriëmie • Noodzaak vroegtijdig stoppen • Haematometra • Laparoscopie / laparotomie • Uterusperforatie = stop ingreep • cave ! darmletsel eventueel laparoscopie

  38. Operative Hysteroscopy UTERINE PERFORATION = TERMINATION

  39. Managing Distention Media Postoperative Bleeding Following Hysteroscopic Myectomy

  40. Instelling 1 = VC =Vapor Cutting 2 = Vaporisatievermogen 3 = Blunt 1 2 3

  41. Instelling Vapor Cutting : VC 1 = max 6 mm. VC 2 = matig 4 mm. VC 3 = zwak 2 mm.

  42. Instelling • Vaporisatievermogen: in Watt • ts. 0 en max 200 • Schakelt autom. in op 130 bij aanzetten

  43. Instelling • Blent = zuiver coagulatie • ts. 0 en 1OO • Start bij aanzetten machine vlg de electrode • Spring : 60 Twizzle : 50 • Ball Point : 24

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