SPECIALIZED SURGICAL EQUIPMENT

USING SPECIALIZED EQUIPMENT IN SURGERY

In the context of surgery, technology refers to a

system that uses devices as well as people to perform specific tasks The focus of technology used in patient care is improvement of care beyond human capability All equipment in the OR has an individual asset tag number, a combination of alphanumeric figures used to identify the particular unit

I. ELECTROSURGERY

HISTORICAL BACKGROUND
The ancient practice of pouring boiling oil into wound

or searing it with hot irons to stop bleeding and infection was extreme, patients were crippled if they survived

 AMBROISE PAR discredited their use in

16th century, they recognized that application of heat accelerates the natural chemical reaction of blood to hasten clotting- this eventually led to the development of ELECTROCAUTERY
ELECTROSURGERY delivers high-

frequency oscillating electric currents through tissue between two electrodes to coagulate or cut tissue

 1906- LEE DEFOREST the FATHER OF

RADIO discovered by accident that a frequency electric current could sever tissue with only slight traces of generated heat
He patented an electrode that cut tissue with an

electric arc created at the point of a dull blade- cold cautery

HARVEY CUSHING- a neurosurgeon first

used the cold cautery W.T. BOVIE together with CUSHING developed the first spark-gap tube generator in the 1920s

PRINCIPLES OF ELECTROSURGERY
Electric current can be

used to cut or coagulate most tissues The initial incision is made by a scalpel to prevent charring and scarring of the skin Electrosurgery can be used on fat, fascia, muscle, internal organs, and vessels

A. ELECTROSURGICAL UNIT
To complete the

electric circuit to coagulate or cut tissue, current flows from a generator to an active electrode, through a tissue, and back to the generator via an inactive dispersive electrode

a) GENERATOR
The machine that produces high-frequency or radio

waves 1. Balanced-output generator- referenced to earth; the machine acts as a ground to earth; current returns to the machine, but if the circuit is broken, the current will find an alternative route back to earth, such as through metal in contact with a body

2. Isolated generator a non-ground-seeking circuit; the flow of current is isolated and restricted to active and dispersive electrodes, and the current returns directly back to the generator; if the circuit is broken, current will not flow

3. Solid-state generatorstransistorized and use diodes and rectifiers to produce current; have safety features such as return monitors to prevent burns and electrocution

 The current may be identical in

frequency, power and amount but vary in quality. Quality depends on damping (the pattern of waveforms by which oscillations diminish after surges of power)

1. COAGULATING CURRENT
a damped waveform has continuous pattern

of surges of current that rapidly diminishes to short periods, or gaps, in which no current is delivered
Produced by spark- gap circuit Damped current coagulates tissue As it approaches the active electrode, the density

of the current increases to produce an intense heat, which sears the end of small and moderatesized vessels to control bleeding on contact

2. CUTTING CURRENT
undamped waveform, produced by

vacuum oscillator, does not diminish but retains a constant output of highfrequency current
Undamped current cuts tissue

3. BLENDED CURRENT
Undamped current can be blended with

damped current to add coagulating effect to the cutting current At the same time that it cuts through a tissue, cutting current accomplishes some coagulation of cells on the surface of the incision and prevents capillary bleeding

ARGON ENHANCED
Argon gas can be incorporated into a

monopolar ESU to create a path between the tissue and the electrode The gas is inert and noncombustible and is easily ionized by electrical current Argon is heavier than air crates less plume The argon-enhances ESU tip is held 60-degree angle and does not contact the tissue during coagulation, thereby causing less tissue damage Care is taken not to cause the gas to enter large open vessels because of the risk of gas embolism

CONTROLS
The type and amount of current are

regulated by controls on the generator A safe general rule for the circulating nurse:
To start with the lowest setting of current that

accomplishes the desired degree of coagulation or cutting and then increase the current at the surgeonss request Verbally confirms and documents the power settings before the generator is activated

b) ACTIVE ELECTRODE
The sterile active

electrode directs flow of current to the surgical site the SCRUB PERSON hands the end of the conductor cord off the sterile field to the CIRCULATING NURSE, who attaches it to the generator

c) INACTIVE DISPERSIVE ELECTRODE (RETURN ELECTRODE)

It disperses high-frequency current released

through the active electrode and provides low current density return from tissues back to the generator

1. BIPOLAR UNITS
the dispersive electrode is incorporated into forceps

used by the surgeon Current does not disperse itself throughout the patient A dispersive pad or return electrode does is not needed because current does not flow through the patient

2. MONOPOLAR UNITS
the electric current flows from the generator to the

active electrode, through the patient to an inactive dispersive electrode, and returns back to the generator

The dispersive electrode is properly placed and connected to the generator to avoid an electrical burn to the patient. The following safeguards are taken:
1. The dispersive electrode should be as close

as possible to the site where the active electrode will be used to minimize current through the body 2. The patient should be in the desired position before the dispersive electrode is applied 3. The dispersive electrode should never be cut to fit

4. The dispersive electrode should cover as large an area of the patients skin as possible in an area free of hair or scar tissue 5. The dispersive electrode should not be placed on skin over a metal implant 6. The integrity of the package of a disposable dispersive electrode should be inspected before use 7. Special care should be taken to ensure that the cord does not become dislodges 8. The connection between the dispersive electrode and generator should be secure and made with compatible attachments 9. A dispersive electrode is not used with bipolar generators

SAFETY FACTORS
Electrosurgery should not be used in the mouth,

trachea, around the head, or in the pleural cavity when high concentrations of oxygen or nitrous oxide are used Electrocardiogram electrodes should be placed away from the surgical site as possible Rings and jewelries should be removed Flammable agents such as alcohol should be used with great care in skin prep If another piece of electrical equipment is used in direct contact with the patient at the same time as the ESU, connect it to a different source of current if possible Monopolar electrosurgery may disrupt operation of an implanted cardiac pacemaker

SAFETY FACTORS
Connection of a bipolar electrode to a monopolar

receptacle may activate current, causing a short circuit Securethe active electrode handle in an insulated holster/container when not in use To prevent fire, only moist sponges should be permitted on the sterile field while the ESU is in use Investigate a repeated request for more current For safety of the patient & personnel, follow instructions for use and care Any manufacturing ESU should be labeled with the problem and taken out of service until cleared for use The patient and personnel should be protected from inhaling plume generated during electrosurgery

II. LASER SURGERY

 LASER is an acronym for light amplification by stimulated emission of radiation

The first surgical laser, the ruby laser was

used in ophthalmology for retinal hemorrhages The argon laser replaced the ruby laser for use in ophthalmology Not until after Jako adapted the CO2 laser to the operating microscope in 1972 did lasers truly become viable adjuncts to the surgical arena

PHYSICAL PROPERTIES OF LASERS

All lasers have a combination of

duration, level, and output wavelengths of radiation emitted when activated

TYPES OF LASERS
1. ARGON LASER
emits blue-green light

beam at wavelengths of 450 and 530 nm this wavelength passes through water and clear fluid, such as cerebrospinal fluid, with minimal absorption it is intensely absorbed by the brown-red pigment of hemoglobin or melanin in pigmented tissue and converted into heat

 a water cooling system is often required to

dissipate heat generated in the argon medium argon lasers coagulate bleeding points or lesions involving many small superficial vessels, such as a port-wine stain they are used primarily to destroy specific cutaneous lesions while sparing adjacent tissue and minimizing scarring they may be used to treat vascular lesions and remove plaque and to coagulate superficial vessels in mucosa, such as in GIT

2. CARBON DIOXIDE LASER

Using CO2, nitrogen, helium

molecular gases, the CO2 laser emits an invisible beam from the mid- to far- infrared range of the electromagnetic spectrum at wavelengths of 9600 and 10, 600 nm. The wavelength is intensely absorbed by water It raises water temperature in cells to the flash boiling point, thus vaporizing tissue

 Vaporization is the conversion of solid tissue

to smoke and gas The plume should be evacuated or suctioned through a filter device from the site of lasing The vaporization and hemostatic actions of the CO2 laser are of value to the surgeon in treating soft tissue and vascular lesions. Large or small masses of tissue can be removed rapidly and efficiently The CO2 laser cannot be used in fluid environment

3. EXCIMER LASER
When organic molecular bonds are broken up by a

photochemical reaction, cool laser energy is emitted Short wavelengths in the ultraviolet to visible blue-green spectrum are produced by gas used in the excimer laser combining with a halide medium The beams they produce offer precision in cutting and coagulating without thermal damage to adjacent tissue

4. FREE ELECTRON LASER

Produces lights waves

as a series of rapid superpulses of high energy and short duration, with minimal thermal damage These light waves can fragment calculi The FEL can be used also for precise cutting if tissues

5. HOLMIUM: YTTRIUM ALUMINUM GARNET (HO:YAG) LASER

Wavelength: 2100 nm The invisible beam in the mid-

infrared range of the electromagnetic spectrum is absorbed by tissues containing water Combined with high-energy pulsed delivery, it penetrates less deeply into tissue than does the ND:YAG laser for more precise cutting and less generalized heating of tissue

 It acts on water in cells without

char or extensive tissue damage Approved use in all joints except the spine It is used in orthopedics to cut, shape, and sculpt cartilage and bone and to ablate soft tissues

6. KRYPTON LASER
The krypton ion gas

laser emits a red-yellow light beam in the visible electromagnetic spectrum at wavelengths of 476.2 to 647.1nm. It is intensely absorbed by pigment in blood and retinal epithelium

 The krypton laser resembles the argon

laser in construction and use It operates from electrical power and is water cooled Used in ophthalmology, it is more versatile than the argon laser in selective photocoagulation of the retina

7. ND:YAG LASER
Neodymium, yttrium, aluminum, and garnet constitute the

solid-state crystal medium from which the light beam in the near-infrared range of the electromagnetic spectrum has a wavelength of 1064 nm It is poorly absorbed by hemoglobin and water but is intensely absorbed by tissue protein The ND:YAG laser has the most powerful coagulating action of all the surgical lasers

 Its continuous or pulsed wave

penetrates deeper into tissues than do other lasers and will coagulate large vessels It is used to coagulate and vaporize large volumes of tissue This versatile laser has applications in rhinolaryngology, urology, gynecology, neurosurgery, orthopedics, and thoracic and general surgery

8. POTASSIUM TITANYL PHOSPHATE LASER

Emits a visible green light at a

wavelength of 532mm Can be focused to a smaller diameter for precision work, such as in the middle ear KTP absorbs most effectively into red or black tissue for coagulation Cooling gases are not necessary, but the system should be water cooled The KTP laser has good cutting properties

9. RUBY LASER
Emits a visible red light at a

wavelength of 694 nm Blood vessels and transparent substances do not absorb this beam A pulsed system, the ruby laser is capable of generating large fields of energy on impact This shock wave effect can injure internal tissues and bone Originally used in ophthalmology, the ruby laser currently is used primarily to eradicate port-wine stain lesions of the skin

10. TUNABLE DYE LASER

Fluorescent liquid dyes or vapors can produce lasing energy Emits a blue-green beam at a wavelength of 430 to 530 nm

for selective destruction of malignant tumor cells A dye laser tuned to 577 nm can be used on vascular lesions Other wavelengths, such as through copper vapor, may be used to treat skin lesions or superficial tumors, such as of the bladder wall This tunable dye laser is used most commonly for photodynamic therapy

PHOTODYNAMIC THERAPY
The patient is injected 24 to 48

hours before laser therapy with a photosensitive drug that is absorbed by normal and malignant tissue Normal tissue gradually releases the drug, but abnormal tissue retains it The abnormal photosensitive is destroyed when exposed to the laser beam. Normal adjacent tissue appears sunburned but is not permanently damaged. All dyes used with tunable dye lasers are potentially toxic and are handled with caution

III. MICROSURGERY

HISTORICAL BACKGROUND
ANTON VAN LEEUWENHOEK (1680)-

developed the compound microscope JOSEPH JACKSON LISTER- introduced antiseptic surgery, perfected the achromatic lens to eliminate color aberrations in the compound microscope 1921- microscope was first used for clinical surgery The first of the current operating microscopes was developed in 1960 by the Zeiss Instrument Company in collaboration with Julius Jacobson

TECHNIQUE OF MICROSURGERY
Performance of surgical

procedures while directly viewing the surgical field under magnification affords surgeons greater visual acuity of small structures The techniques themselves for handling instruments, sutures, and tissues are different and infinitely more complex, precise, and time consuming because of the meticulous skill involved

ADVANTAGES OF MICROSURGERY
Microsurgery provides unique advantages in the

restoration of wholeness and function of the body, such as restitution of hearing, vision, tactile sensation, circulation, and/or motion In general, microsurgery allows the following:
Dissection and repair if fine structures through better

visualization Adaptation of surgical procedures to individual patient requirements Diminution of surgical trauma and complications because of safer dissection Superior focal lighting of the surgical field, particularly in deep areas

OPERATING MICROSCOPE
All operating

microscopes incorporate the same essential components: an optical lens system and controls for magnification and focus, an illumination system, a mounting system for stability, an electrical system, and accessories

OPTICAL LENS SYSTEM

The ability to

enlarge an image is known as magnifying power

COMPONENTS
The heart of the optical

system is the body, which contains the objective lens The head or binocular oculars through which the surgeon looks are physically and optically attached to the body

MAGNIFICATION
The ability of the

microscope to magnify depends on the design and quality of the parts in addition to the resolving power

FOCUS
Focusing is accomplished manually

or by a foot-controlled motor that raises and lowers the body of the microscope

ILLUMINATION SYSTEM
The intensity of

illumination can be varied by controls mounted on the support arm of the body The operating microscope has two basic sources of illumination: paraxial and coaxial

1. PARAXIAL ILLUMINATORS
One or more light

tubes contain tungsten or halogen bulbs and focusing lenses Light is focused to coincide with the working distance of the microscope

2. COAXIAL ILLUMINATORS
This type of

illumination is called coaxical because it illuminates the same area in the same focus as viewing, or objectives, field of the microscope

MOUNTING SYSTEMS
The body, the optical portion, is

mounted on a vertical column that may be supported by the floor, ceiling, or wall, or by attachment to the operating bed

1. FLOOR MOUNT
the base of the vertical support, which rests on the floor, has retractable casters for ease in moving the entire instrument

2. CEILING MOUNT
Either a fixed or track-

mounted model, provides freer floor space The fixed unit is suspended from a telescoping column attached directly to the ceiling

3. WALL MOUNT
the microscope bracketed by a flexible arm to a stable wall

OPERATING BED MOUNT

smaller

microscopes may be mounted on the framework of the operating bed. This system has many disadvantages and thus this is not popular

ELECTRICAL SYSTEMS
The same precautions are observed

with the operating microscope as with any electrical equipment as with any electrical equipment in the OR. Switches and wall interlocks should be explosion-proof.

ACCESSORIES: 1. ASSISTANTS BINOCULARS

A separate optical body

with a non-motorized, hand-controlled zoom lens can be attached to the main microscope body for use by the assistant This mechanism can be focused in the same plane as the surgeons oculars

2. BROADFIELD VIEWING LENS

A low-power magnifying glass is

used for grasping needles or for getting an overall view of the field adjacent to the objective

3. COUPLINGS
They allow versatility in positioning

the microscope for specific applications A coupling piece lets surgeons change the angle for side-to-side or front-to-back viewing

4. CAMERAS
Still photographic,

motion picture, videotape, and television cameras may be attached to the beam splitter, permitting filming of the surgical procedure

5. LASER MICROADAPTER
Laser beams can be directed through the operating microscope

7. REMOTE FOOT CONTROLS

It is more

convenient for the surgeon to use motorized foot controls for functions such as focus or zoom

8. MICROSCOPE DRAPES
The entire working mechanism and support arm

of the microscope are encased in a sterile drape Draping the entire microscope permits it to be brought into the sterile field so that the surgeon can position the body and adjust the optics Disposable drapes that are heat-resistant, lintfree, non-reflective, transparent, and quiet are available to fit the configuration of all microscopes and attachments

 The SCRUB PERSON

slides the drape over the body of the microscope, with hands protected as for draping a Mayo stand The CIRCULATING nurse helps guide the drape toward the vertical column and secures it The SCRUB PERSON secures the drape to the oculars

GENERAL CONSIDERATION IN MICROSURGERY

PATIENT The patient is prepared as for standard surgical procedure He/she should be positioned comfortably and safely with the operating bed locked in position.
ANESTHESIA If a general anesthesia is to be administered, the anesthesia provider should be informed in advance of the surgeons intention to use microscope

 STABILITY OF THE SURGICAL FIELD

A vital factor for a successful microsurgery is

stability of the surgical field, microscope, and surgeons hands

ARMRESTS AND CHAIR
It is important that the surgeons hands be

adequately supported, because a shift even 1/25 inch (1mm) can alter the precision of motion, particularly at high magnifications Support of the surgeons arm should be continuous from shoulder to hand to give stability and minimize tremor, especially in fine finger movements