Specialized Surgical Equipment

7/27/2019 Specialized Surgical Equipment

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SPECIALIZED

SURGICAL



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 PARÉ discredited their use in

16th

century, they recognized thatapplication 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 afrequency 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- “coldcautery”

• 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 beused to cut or coagulate mosttissues

• The initial incision ismade by a scalpel toprevent charring andscarring of the skin

• Electrosurgery can beused on fat, fascia,muscle, internalorgans, and vessels



A. ELECTROSURGICAL UNIT•To complete theelectric circuit to

coagulate or cut

tissue, current flowsfrom a generator to

an active electrode,

through a tissue, andback to the generator

via an inactive

dispersive electrode



a) GENERATOR• The machine that produces high-frequency or radiowaves

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 currentwill find an alternative route back to earth, such as

through metal in contact with a body



2. Isolated generator —

a non-ground-seekingcircuit; the flow of current

is isolated and restricted

to active and dispersiveelectrodes, and the

current returns directly

back to the generator; if the circuit is broken,

current will not flow



3. Solid-state generators-

transistorized and use diodes andrectifiers to produce current; have safety

features such as return monitors to

prevent burns and electrocution



•The current may be identical infrequency, 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 densityof the current increases to produce an intense

heat, which sears the end of small and moderate-

sized vessels to control bleeding on contact



2. CUTTING CURRENT

•undamped waveform, produced byvacuum oscillator, does not diminish

but retains a constant output of high-

frequency 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 thesurface 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 thesurgeons’s request

• Verbally confirms and documents the power

settings before the generator is activated



b) ACTIVE ELECTRODE•The sterile activeelectrode directs flowof current to thesurgical site

• the SCRUB PERSONhands the end of theconductor cord off the

sterile field to theCIRCULATINGNURSE, who attachesit 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 thepatient



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 activeelectrode will be used to minimize current

through the body

2. The patient should be in the desired positionbefore 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 patient’s skin as possible in an area free

of hair or scar tissue5. 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 electrodeand 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 directcontact 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 permittedon 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 tothe 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 LASERS1. ARGON LASER

• emits blue-green lightbeam at wavelengths of 450 and 530 nm

• this wavelength passesthrough water and clear fluid, such as cerebrospinalfluid, with minimalabsorption

• it is intensely absorbed bythe brown-red pigment of hemoglobin or melanin inpigmented tissue andconverted 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, heliummolecular gases, the CO2

laser emits an invisible beamfrom the mid- to far- infrared

range of the electromagneticspectrum at wavelengths of 9600 and 10, 600 nm.

• The wavelength is intensely

absorbed by water • It raises water temperature incells 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 andcoagulating 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 minimalthermal damage

• These light waves can

fragment calculi

• The FEL can be used

also for precise cutting

if tissues



5. HOLMIUM: YTTRIUM ALUMINUMGARNET (HO:YAG) LASER

• Wavelength: 2100 nm

• The invisible beam in the mid-infrared range of theelectromagnetic spectrum isabsorbed by tissues containingwater

• Combined with high-energypulsed delivery, it penetratesless deeply into tissue than doesthe ND:YAG laser for moreprecise cutting and lessgeneralized heating of tissue



•It acts on water in cells withoutchar or extensive tissue damage

• Approved use in all joints exceptthe spine

•It is used in orthopedics to cut,

shape, and sculpt cartilage andbone and to ablate soft tissues



6. KRYPTON LASER

•The krypton ion gaslaser emits a red-yellow

light beam in the visible

electromagneticspectrum at

wavelengths of 476.2 to

647.1nm.• It is intensely absorbed

by pigment in blood and

retinal epithelium



•The krypton laser resembles the argonlaser in construction and use

• It operates from electrical power and is

water cooled

•Used in ophthalmology, it is more

versatile than the argon laser inselective 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 thenear-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 doother lasers and will coagulate large

vessels

• It is used to coagulate and vaporizelarge 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 effectivelyinto red or black tissue for

coagulation

• Cooling gases are notnecessary, 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 iscapable 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 DYELASER

• 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 beused 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 aphotosensitive drug that isabsorbed by normal andmalignant tissue

• Normal tissue gradually releasesthe drug, but abnormal tissueretains it

• The abnormal photosensitive isdestroyed when exposed to the

laser beam. Normal adjacenttissue appears sunburned but isnot permanently damaged. Alldyes used with tunable dye lasersare 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 lensto 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 surgicalprocedures while directlyviewing the surgical fieldunder magnification affords

surgeons greater visualacuity of small structures

• The techniques themselvesfor handling instruments,sutures, and tissues aredifferent and infinitely morecomplex, precise, and timeconsuming because of themeticulous skill involved



ADVANTAGES OF MICROSURGERY

• Microsurgery provides unique advantages in therestoration 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 operatingmicroscopes

incorporate the same

essential components:

an optical lens system

and controls for

magnification and

focus, an illuminationsystem, a mounting

system for stability, an

electrical system, and

accessories



OPTICAL LENS SYSTEM

•The ability to

enlarge animage is known

as magnifying

power



COMPONENTS•The heart of the opticalsystem is the body,which contains the

objective lens•The head or binocular oculars through which

the surgeon looks arephysically and opticallyattached to the body



MAGNIFICATION

•The ability of the

microscope to

magnify dependson the design and

quality of the parts

in addition to theresolving power



FOCUS•Focusing is accomplished manuallyor 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 supportarm of the body

• The operating

microscope has twobasic sources of

illumination: paraxial

and coaxial



1. PARAXIAL ILLUMINATORS

• One or more light

tubes contain

tungsten or halogen

bulbs and focusinglenses

• Light is focused to

coincide with theworking distance of

the microscope



2. COAXIAL ILLUMINATORS

•This type of

illumination is called

coaxical because itilluminates the same

area in the same

focus as viewing, or objectives, field of

the microscope



MOUNTING SYSTEMS

•The body, the optical portion, ismounted on a vertical column that may

be supported by the floor, ceiling, or

wall, or by attachment to the operatingbed



1. FLOOR MOUNT

the base of the

vertical support,

which rests onthe floor, has

retractable

casters for easein 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 columnattached directly to the

ceiling



3. WALL MOUNTthe microscope

bracketed by aflexible 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 anyelectrical equipment in the OR.

Switches and wall interlocks should be

explosion-proof.



ACCESSORIES:

1.ASSISTANT’S

BINOCULARS • A separate optical bodywith a non-motorized,hand-controlled zoom

lens can be attached tothe main microscopebody for use by theassistant

• This mechanism can befocused in the sameplane as the surgeon’soculars



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-sideor front-to-back viewing



4. CAMERAS•Still photographic,motion picture,videotape, and

televisioncameras may beattached to the

beam splitter,permitting filmingof the surgicalprocedure



5. LASER MICROADAPTER

Laser beams canbe directed

through the

operatingmicroscope



7. REMOTE FOOT CONTROLS

•It is more

convenient for

the surgeon touse motorized

foot controls

for functionssuch 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, lint-

free, non-reflective, transparent, and quiet areavailable 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 nursehelps guide the drape

toward the vertical column

and secures it• The SCRUB PERSON

secures the drape to the

oculars

GENERAL CONSIDERATION IN



GENERAL CONSIDERATION INMICROSURGERY

• PATIENT• The patient is prepared as for standard surgicalprocedure

• He/she should be positioned comfortably andsafely with the operating bed locked in position.

• ANESTHESIA• If a general anesthesia is to be administered,the anesthesia provider should be informed inadvance of the surgeon’s intention to usemicroscope



• STABILITY OF THE SURGICAL FIELD• A vital factor for a successful microsurgery is

stability of the surgical field, microscope, and

surgeon’s hands

• ARMRESTS AND CHAIR

• It is important that the surgeon’s hands beadequately supported, because a shift even 1/25

inch (1mm) can alter the precision of motion,

particularly at high magnifications

• Support of the surgeon’s arm should be

continuous from shoulder to hand to give stability

and minimize tremor, especially in fine finger

Specialized Surgical Equipment

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