Page 19 - Journal of WALS

WJOLS

A Comparative Study of the use of Different Energy Sources in Laparoscopic Management of Endometriosis-Associated Infertility

Endoscopic surgery is precise enough that adhesions can dense tissue between both the active and return
be excised without destroying surrounding tissue or damaging electrodes is difficult.
vital structures, such as the ureters, bladder and bowel. • Ultrasonic surgical dissection (Harmonic scalpel): This
Removal of all adhesions and restoration of the normal uses mechanical energy at 55,500 vibrations/sec, thus
anatomic relationship of the pelvic organs enhances the disrupting hydrogen bonds and forming a coagulum. It is
fertility. ideal for dividing and simultaneously sealing small and
medium vessels with less instrument traffic, reduction in
OPERATIVE TECHNIQUES operating time, less smoke and no electrical current.
• High velocity and high pressure water-jet dissection: This
A variety of mechanisms, involving some form of physical
energy, can be used to divide tissue and enable hemostasis. 24 produces clean cutting of reproducible depth. Other
advantages are the cleansing of the operating field by the
The available modalities for dissection in minimal access surgery turbulent flow zone. Problems encountered with the use of
include: this modality include the ‘hail storm’ effect causing excessive
• Blunt dissection: Can be done with a closed scissors tip, misting which obscures vision, lack of hemostasis, difficulty
grasper, inactive suction cannula, heel of inactive in gauging distance and poor control of depth of the cut.
electrosurgery hook or a pledget. Blunt dissection is used • Hydrodissection: Hydrodissection uses the force of
to open planes and expose structures, especially when the pulsatile irrigation with crystalloid solutions to separate
anatomy is obscured by adhesions. Insignificant hemostatic tissue planes. The operating field is kept clear. However, no
capability is the main disadvantage. hemostasis is achievable.
• Sharp scissors dissection: Implants are grasped and • Argon beam coagulator: The argon beamer is used in
removed by precise dissection with scissors. This allows conjunction with monopolar electrosurgery to produce
histological confirmation and avoids destruction of fulguration or superficial coagulation. Less smoke is
peripheral tissue. The main disadvantage is the risk of produced because there is lesser depth of tissue damage.
hemorrhage which can usually be controlled by bipolar However, a significant drawback of this modality is an
cauterization. increase in intra-abdominal pressure to potentially
• High frequency radio wave electrosurgery: This is the most dangerous levels due to high-flow infusion of argon gas.
convenient and most risky method of dissection in minimal • Laser dissection: The degree and extent of thermal damage
access surgery. Most of the complications in laparoscopic produced by laser depends on the structure, water content,
surgery are due to use of energized instrument (1-2%). pigmentation, optical and thermal properties, and perfusion
– HF monopolar electrosurgery: Monopolar electro- of the tissue.
surgery has become the most widely used cutting and Each of the various types of laser available has a specific
coagulating technique in minimal access surgery. This clinical application.
permits complete and deep coagulation of the nodules. – The argon laser coagulator is the ideal method of
Its main advantage is its efficiency and the absence of treating small red endometriotic deposits.
hemorrhage. Associated complications include thermal – CO laser vaporization: This is the most efficient
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injury to nontargeted organs due to insulation failure, technique for superficial ablation permitting a complete,
direct coupling or capacitive coupling, absence of precise, controlled and bloodless destruction of the
biopsies and extensive destruction of the surrounding implants. It can be used on multiple and widespread
tissue. Other problems encountered include effect on disease even if the diagnosis of some lesions is
pacemakers, return electrode burns and toxic smoke. doubtful, with minimal risk to adjacent organs, such as
– Bipolar diathermy: A bipolar system is safer as the the ureter and bowel. Its major drawback is production
current does not pass through the patient but instead of smoke. It is relatively inexpensive (compared to other
returns to the generator via the receiving electrode after lasers).
passage through the grasped tissue. Its main advantages – CO laser excision: This method is preferred for large
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are absence of hemorrhage and restriction of thermal nodules as vaporization is a slow procedure. CO laser
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injury to the surrounding tissue. The main excision is equivalent to sharp excision but avoids the
disadvantages are superficial coagulation and, therefore, problems of hemorrhage and is therefore faster. It is
a potentially incomplete treatment of deeper implants. mainly useful for removing rectovaginal nodules.
The primary electrothermal tissue effect is limited to – Other laser procedures: Nd: YAG laser, KTP laser and
desiccation, not cutting. It requires slightly more time holmium laser have also been used to treat endometriotic
than monopolar coagulation because of lower power implants. These lasers are mainly coagulating, and
settings and bipolar generator output characteristics. therefore the destruction is less precise than with the
Hemostasis over a large area is not possible. Grasping CO laser. They are more ergonomic as they can be
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World Journal of Laparoscopic Surgery, May-August 2011;4(2):89-95 91