Wednesday, February 13, 2008
Not many surgeons nowadays would want t0 operate without an electrosurgery unit, but it wasn't all that many years ago that everyone did. In fact, when dinosaurs roamed the earth and I was still in training, a couple of my teachers refused to use it at all. So I learned both ways. Cutting only with a knife, and controlling bleeding only with clamps and ties and sutures has a certain elegance; grace, even, as tying a small vessel requires gentleness and coordination of the fingers so as not to avulse the knot from the bleeder. But it can also be tedious. I wear size 8 1/2 or 9 gloves.
An electrician or physicist I'm not, so I can only say that electrosurgery refers to any of several devices that provide the surgeon with a pencil-like hand unit, connected to some sort of magic box which sends little electrons or something to that hand unit, which then arc to the patient in at least two different modes: one that's best suited for cutting, and one that serves to cauterize; ie, cook tissue to make it stop bleeding ("dead meat don't bleed," a colleague liked to say). I guess the first such devices, widely available only in the last fifty years or so, were those invented by a guy named Bovie. That name has become like Kleenex to facial tissue -- pretty much used generally and generically to refer to any unit, which I assume must annoy the other manufacturers. "Bovie," the surgeon says, and he or she receives a hand-unit most likely made by someone else.
In those days of yore (or mine) the Bovie looked like something from a B-grade science fiction movie, with knobs and buttons and dials; having a fat handle and foot pedals to operate it. "Turn the coag to sixty," the orthopedist would say when encountering bleeding, and the dial would be rotated far to the right, the surgeon would step on the left-hand pedal (there was one each, for cutting current and for coagulating current). Spzzziiiiit the arc sounded, while the floor unit emitted a low-pitched and disquieting hum. Now, we have tidy little boxes with digital readouts, buttons marked ">" and "<" and spiffy hand units with a rocker switch to go from cut to coag, with no need for a pedal. (Most surgeons, I think, like to dance their index finger on that switch -- or buttons, which some "pencils" have -- but I preferred the side of my thumb, which I could rock back and forth without changing my grip.)
I didn't much use electro surgery for cutting, except for going through muscle, preferring the lesser tissue-trauma and greater speed of a knife, cauterizing as needed. You can scald directly, by touching the bleeder with the tip of the unit and firing away. More precise is to clasp the vessel with fine forceps, then touch the blade of the pencil to the metal of the forcep. "Buzz me," is what I'd say after forceptualizing the bleeding point; my assistant would touch the bovie to my instrument and activate it, and I could let go of the tissue at the instant I was happy. Excellent control. Cautery is great for (some kinds of) bleeding from the liver. The old units had a ball-ended option: turn the phaser to stun or kill, press the ball into the wetness, and blast away. It would, of course, smell exactly like grilling liver, and smoke would rise, white, profuse, acrid. (Concerns have been raised and remain, regarding health hazards to the team inhaling that stuff.) "Turn up the coag," I'd request, "and get us some sterile onions."
Sometimes, when it's cranked way up, you can see little lightning bolts running away from the point, for a few millimeters, within the tissues. Spidery sparks, singeing. A charcoal-like coagulum of tissue and baked black blood forms; depending on the nature of the bleeding, blood may continue to ooze from underneath and around, making the field look like an evil-staring eye. Pulling away the cautery unit, stuck like a grill on steak, sometimes also pulls away the char, and you have to start again.
Since sliced bread, the greatest invention is "spray mode" cautery. Using some electromagical manipulations, these new units can be adjusted to provide a white and sizzling rivulet which leaps as if from a Van de Graaf generator, lighting the space between tissue and tip, covering a relatively broad field of fire, cooking without the need for touching. Excellent! No avulsion of clot. Perfect on liver or spleen, where suturing is tricky.
Gathering dust in many an OR are uber-expensive laser units, once sold to hospitals as the next wave, the future of surgical cutting. Better than electric current, and what the public is demanding, they were told. Half-right. For most operations with which I'm familiar, laser offers absolutely no advantage other than marketing. (It has a rightful place in eye surgery, various skin procedures...) In laparoscopic surgery (where laser was predicted to be the ne plus ultra and isn't), there are cleverly conceived devices that combine in one wand, cautery, suction, and irrigation. In the early years of laparoscopy, that was precisely what I thought was needed, and, by golly, here it is. When scissors are added, a lot of annoying motion (taking one instrument out, inserting another, back and forth) will be eliminated. Surgeons nowadays are deeply beholden to engineers.