Monopolar Energy Simulation: Chicken Thigh Model

Transcription

1 Mnplar Energy Simulatin: Chicken Thigh Mdel Lisa Cha, MD, Magee-Wmen s Hspital f UPMC Nicle Dnnellan, MD, Magee-Wmens Hspital f UPMC Amanda Ecker, MD, Oregn Health and Science University Ted Lee, MD, Magee-Wmen s Hspital f UPMC Deirdre Lum, MD, Stanfrd University Medical Center Christina Ramirez, MD, Magee-Wmen s Hspital f UPMC

2 Objectives By the end f this unit, the learner shuld be able t d the fllwing: Explain the use f mnplar energy Describe nrmal retrperitneal anatmy Describe techniques t avid ureteral injury Demnstrate skill in perfrming surgical dissectin with mnplar energy

3 Electrsurgery Electrsurgery is a high-frequency alternating current passing thrugh tissue The patient is a necessary part f cmpleting this circuit Tw types: Biplar Mnplar Curtesy f APGO:

4 Electrsurgery Electrsurgery ccurring at greater than 100 khz reduces the risk f muscle cntractin. Curtesy f APGO:

5 Mnplar Electrsurgery Active electrde is at the surgical site Dispersive electrde at anther site n the patient Current flws thrugh the patient between the tw electrdes Curtesy f APGO:

6 Dispersive Electrde Dispersive electrde has large surface area. This decreases current density t prevent tissue heating Necessary t cmplete the circuit when using mnplar energy Curtesy f APGO: educatin/wmen/electrsurgery.html

7 Wavefrms Current high lw Curtesy f APGO: Wavefrm ptins fr mnplar energy: Cut Blend Cagualatin These wavefrms represent variatins in the current and vltage

8 Wavefrms and Tissue Effects Utilizatin f these three wavefrms (cut, blend, cag) can result in three different tissue effects The three tissue effects that we will review are: Vaprizatin Fulguartin Dessicatin

9 Vaprizatin With vaprizatin, the tissue is divided by rapidly heated cells Energy shuld be activated withut tissue cntact n Cut wavefrm (high current) This results in deep injury with minimal lateral spread Useful fr ureterlysis r excisin f endmetrisis Curtesy f APGO:

10 Fulguratin With fulguratin, there is superficial burning f a wide area Energy shuld be activated withut tissue cntact n Cag wavefrm (lw current) Useful fr ablatin f superficial endmetrisis Curtesy f APGO:

11 Dessicatin Dessicatin results in a deep, penetrating tissue burn Energy shuld be activated AFTER cntact with tissue using either cut r cag wavefrm Useful fr ablatin f endmetrisis Curtesy f APGO:

12 Summary: Electrsurgical Effects Nn-cntact Cntact Cut Vaprizatin Desiccatin Cag Fulguratin Desiccatin Curtesy f APGO:

13 Retrperitneum: Imprtance Cntains Uterine artery Ureter Lcating these structures retrperitneally can decrease inadvertent injuries Pelvic pathlgy is usually intraperitneal r cntained within the pelvis, usually sparing the retrperitneum Can ften be managed thrugh a retrperitneal apprach

14 Uterine Artery Retrperitneum: Structures Originates frm the anterir divisin f the internal iliac artery in the retrperitneum May share a cmmn rigin with the bliterated umbilical artery/median umbilical ligament Travels thrugh the cardinal ligament and passes OVER the ureter Jins the uterus near the level f the internal cervical s and gives ff branches that run superirly twards the uterine crpus and inferirly twards the cervix

15 Ureter Retrperitneum: Structures Retrperitneal structure that runs frm the renal pelvis t the bladder Apprximately cm in length Pelvic brim divides the ureter int abdminal and pelvic segments Always fund n the psterir leaf f the brad ligament Can als be divided int upper, middle, and lwer segments

16 Between the ureterpelvic junctin t the upper brder f the sacriliac jint Upper brder t lwer brder f sacriliac jint Inferir brder f the sacriliac jint t the uretervesical junctin

17 Median umbilical ligament Uterine artery External iliac artery Ureter

18 Anatmic Curse f the Ureter Ureters enter the pelvis at the pelvic brim and crss frm lateral t medial Left ureter enters the pelvis by crssing ver bifurcatin f left cmmn iliac artery Right ureter enters the pelvis by crssing the right external iliac artery

19 Left ureter crsses ver left cmmn iliac

20 Right ureter crsses ver right external iliac artery

21 Anatmic Curse f the Ureter Ureters travel int the pelvis alng the varian vessels Descend int the pelvis within a peritneal sheath (ureteric fld) attached t the medial leaf f the brad ligament and the lateral pelvic side wall Run alng the pelvic side walls just abve the internal iliac arteries

22 Anatmic Curse f the Ureter Just inferir t internal cervical s, ureter passes under the uterine arteries ( water under the bridge ) Passes thrugh arelar tissue f the tunnel f Wertheim Passes by the anterlateral frnix f the vagina and enters the psterir aspect f the bladder apprximately 5 6 cm apart They run bliquely thrugh the bladder wall fr 1.5 cm befre terminating at the trigne

23 Atlas f Pelvic Surgery Cliffrd Wheeless

24 Ureteral Bld Supply Multiple vessels cntribute t the bld supply f the ureter: Renal Artery Cmmn Iliac artery Ovarian Artery Arta In the abdmen, the ureter receives bld supply frm small arteries appraching it medially In the pelvis, the ureter receives its bld supply frm vessels appraching it laterally

25 Hw t Avid Ureteral Injuries Avid ischemic injuries by staying utside the adventitial sheath surrunding the ureter Apprximately 0.4 2% rate f injury during benign pelvic surgery Cnsider the use f ureteral stents in identificatin f the curse and lcatin f the ureter

26 References Assciatin f Prfessrs f Gyneclgy and Obstetrics DeLancey J. Surgical anatmy f the female pelvis. Te Linde s Operative Gyneclgy, Srinla O, Begum R. Preventin and management f ureteric injuries. Hsp Med 2005; 66:329. Underwd P. Operative injuries t the ureter. Te Linde s Operative Gyneclgy, 2011.