-Director, Reproductive Endocrinology & Infertility, Georgia Baptist Medical Center
-Assistant Clinical Professor, Department of Obstetrics & Gynecology, Emory University School of Medicine
Abstract: Bipolar electrosurgery offers an effective means of performing endoscopic adhesiolysis and excision of endometriosis. The Everest Medical BiLAP Bipolar Probe, (figure 1) is a unique instrument providing the cutting and coagulation effectiveness of monopolar energy while avoiding the associated risks.
Monopolar has high voltages, gated currents and distant return electrodes. Also, it may result in greater peripheral tissue injury, subjecting the patient to injury from capacitive coupling and sparks. With bipolar technology, the electrical circuit is completed as current flows between the two adjacent hook tip electrodes, avoiding current dispersion and the risk of sparking; while maintaining sufficient voltage for cutting levels. The generator can be operated in a low voltage mode for coagulation to provide hemostasis. These characteristics make the BiLAP Bipolar Probe an excellent choice for adhesiolysis and excision or retroperitoneal endometriosis.
Introduction: Endoscopic management of pelvic adhesions and endometriosis has relied on the intra-abdominal application of an energy source for both coagulation and division of tissue. Traditionally, this has involved lasers or monopolar electrocautery. However, because of the high cost associated with laser surgery and safety concerns associated with monopolar surgery, we decided to evaluate the use of bipolar electrosurgery as an alternative to these techniques.
Traditional monopolar surgical instruments provide cutting levels (~3000volts peak to peak [PEP] continuous current) and coagulation levels (~6000 volts PEP gated current) capabilities. It involves a current flowing from the active electrosurgical element that diffuses through tissue until the return electrode is reached. Bipolar instruments allow the electrical energy to pass from one electrode to another in close visual proximity. With instrument tip dual electrodes, current flows through less tissue (lower impedance) than with monopolar electrosurgery. Consequently, bipolar electrocautery requires less power than monopolar.
Bipolar electrosurgery offers many safety advantages as well: (1) return electrode burns are eliminated (2) lateral thermal injury is avoided as the current flow is confined to the small volume of tissue between the electrodes rather than through the patient to a return electrode (3) capacitance coupling and alternate site burns are eliminated, and (4) reduced energy levels are required.
Bipolar surgery has been applied primarily to provide hemostasis and to achieve tissue coagulation. To accomplish bipolar electrocautery, electrosurgical generators have been designed with specific output characteristics. These generators work best at low tissue impedance. As tissue desiccation occurs, a dramatic drop in current is seen. While these bipolar generators have been designed to allow safe electrocautery, they will not provide a sustained power output of sufficient intensity to achieve tissue cutting. Two solutions to this problem exist.
The first solution involves the use of the monopolar outputs with bipolar endoscopic cutting instruments. This can be accomplished easily by hooking the lead from one of the bipolar electrodes into the generator's return electrode jack and the other lead into the active electrode jack using a cord provided by the manufacturer. This eliminates the necessity of a return electrode/grounding pad. Caution is required because high power settings (>30 watts) will likely destroy the electrodes and provide limited coagulation during the cutting process.
The second solution involves using a computer controlled electrosurgical generator with a macrosurgical bipolar setting. These generators provide a sufficient power output over a wide range of impedance to efficiently cut tissue at the lowest power output. This results in less char and less smoke production than using the generator's monopolar output jacks. a micro-bipolar setting allows for low voltage coagulation with a rapid current falloff as tissue is desiccated. This setting is used for coagulation with micro-bipolar forceps and does not provide sufficient energy for cutting tissue.
Materials & Methods: The purpose of this study was to determine if the BiLAP® Bipolar Probe provides controlled cutting and coagulation necessary for precise tissue excision during endoscopic management of pelvic adhesions and endometriosis.
The clinical population for this study consisted of 30 patients who underwent endoscopic evaluation and management of infertility, endometriosis and pelvic pain. Three clinical factors used to evaluate the device were: (1) the ability to cut and coagulate tissue, (2) the precision and safety of the instrument, and (3) the ease with which the BiLAP Bipolar Probe could be used to accomplish the surgical goal. All patients underwent preoperative bowel prep and general endo-tracheal anesthesia and had placement of up to three additional accessory ports after the laparoscope was inserted. Adhesions were placed on tension and excised using the BiLAP Bipolar Probe to cut all sites of attachment.
After identifying all lesions, endometriosis excision was performed. Lesion sites on the pelvic side wall or dome of the bladder were excised by elevating and incising with the BiLAP Bipolar Probe. Hydrodissection was performed under the peritoneum using Ringers lactated solution. Then, the edges of the incision were grasped and the L-Hook BiLAP Bipolar Probe was used to elevate the peritoneal surface while applying cutting current. The lesion was then excised. For lesions in the posterior cul de sac, hydrodissection was used less often, but otherwise, tissue excision was carried out in a similar fashion.
Results & Discussion: The BiLAP Bipolar Probe allowed for rapid excision of filmy peritubal adhesions as well as those that were densely adherent to previous laparotomy scars. In clinical application, this device excised adhesions close to the fallopian tube or other abdominal viscera with limited risk of injury due to lateral current flow.
The BiLAP Bipolar Probe was used to grasp and elevate tissue prior to applying energy, providing safety while excising retroperitoneal endometriosis. By placing gentle counter traction the tips of the instrument could be seen through the tissue prior to cutting allowing identification of tissue prior to division. Cutting with instrument tip and limiting the amount of tissue in the tip elbow, the BiLAP Bipolar Probe increased cutting speed. While large lesions were easily excised, the smaller lesions under 3-5mm were often vaporized.
Identification and excision of retroperitoneal endometriosis was made safer by visualization of the course of the ureter. The peritoneum in the area of the ureter could be elevated and safely incised with the L-hook tip design. The incision was then enlarged to demonstrate the course of the ureter, facilitating the safe removal of retroperitoneal disease.
Coagulation of bleeding was easily controlled with application of low energy coagulation current (<15 watts setting). Coagulation was enhanced by the broad-based electrodes at the posterior portion of the tip. Applying gently pressure, wetting the surface with lactated Ringer's solution and allowing sufficient time for penetration of the heat generated by the electrocautery effect provided adequate hemostasis for small blood vessels.
Using the BiLAP Bipolar Probe with the generator's monopolar jacks resulted in increased char and smoke formation compared to the computer controlled macro-bipolar setting. Smoke generation was judged to be less than is associated with CO2 laser and consistent with that associated with other endoscopic applications of monopolar energy. Char easily was removed using the cleaning tool provided with the device. An insulated sheath is incorporated into the device, protecting the electrodes during insertion and removal. The sheath also serves to cover the device, thereby avoiding inadvertent electrical injury. An irrigation port also allows instillation of fluid for hydrodissection or to clean the electrodes. No complications occurred as a result of the device and no device failures were recorded.
Conclusions: The Everest Medical BiLAP Bipolar Probe is an effective device for endoscopic adhesiolysis and excision of endometriosis. When compared to monopolar cutting, bipolar cutting can be accomplished effectively with increased safety and with decreased lateral thermal injury. Connecting the BiLAP Bipolar Probe to a newer, computer controlled macro-bipolar generator insures rapid cutting at the lowest possible energy setting and minimizes smoke and char formation as compared to the monopolar jacks on an older electrosurgical generator. Although there is a learning curve associated with the use of any new device, the transition from monopolar electrosurgey should be relatively easy. No injuries, complications or device failures were experienced.
RELATED VIDEOS:
Note: these videos may require several minutes to download.
 | Resection of Endometriosis | As endometriosis can grow below the surface of the peritoneum, I believe that excision of endometriosis leads to better results than laser vaporization. 5.6 meg quicktime video |
| Lysis of Adhesions | The use of bipolar electrosurgery is a safe and cost effective alternative to laser surgery that offers similar results. Adhesions must be cut at both ends and removed and not just cut in the middle to achieve the best results 1.0 meg avi video |
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