Bipolar in hysteroscopy

Dr Rajesh Gajbhiye

Monopolar is traditionaly used

Technological advance have made new generation equipments to use Bipolar electrodes

Uses Saline or Ringers making the procedure not only safer but gets it to the office as well to further reduce the cost

See and treat

bull Option to treat benign pathology in the same sitting

bull Saves time

bull Avoids return visits

bull Reduces the anxiety of pt between the diagnosis and treatment

bull Bipolar can be used with smaller diameter hysteroscopeNo dilatation is required

Electrical circuit

Monopolar

The entire patient is involed in the circuit

Greater chances of current diversion to undesirable locations

Bipolar circuit

Current flows between two electrodes the circuit is closed by placing tissue between two electrodes

less chance of diversion

Types of electrode

bull Spring twizzle and ball electrode

bull Spring tip for hemostatic vaporization large areas

bull Ball tip for precise vaporization

bull Twizzle tip for hemostatic resection and morcellation of tissue

bull Cutting loop similar to traditional resectoscopy

bull It allows vaporisation of tissue

bull Cuts and dessicates the tissue

bull Instantaneous tissue vaporization eliminates resection chips thus permitting continuous visualisation of tissue effect

bull Cutting power and coagulation is better due to plasma effect

bull Vision during resection is not disturbed

bull A vaporizing electrode may prevent significant blood loss during myoma resection by sealing blood vessels as the tissue is vaporized13

Monopolar is traditionaly used

Technological advance have made new generation equipments to use Bipolar electrodes

Uses Saline or Ringers making the procedure not only safer but gets it to the office as well to further reduce the cost

See and treat

bull Option to treat benign pathology in the same sitting

bull Saves time

bull Avoids return visits

bull Reduces the anxiety of pt between the diagnosis and treatment

bull Bipolar can be used with smaller diameter hysteroscopeNo dilatation is required

Electrical circuit

Monopolar

The entire patient is involed in the circuit

Greater chances of current diversion to undesirable locations

Bipolar circuit

Current flows between two electrodes the circuit is closed by placing tissue between two electrodes

less chance of diversion

Types of electrode

bull Spring twizzle and ball electrode

bull Spring tip for hemostatic vaporization large areas

bull Ball tip for precise vaporization

bull Twizzle tip for hemostatic resection and morcellation of tissue

bull Cutting loop similar to traditional resectoscopy

bull It allows vaporisation of tissue

bull Cuts and dessicates the tissue

bull Instantaneous tissue vaporization eliminates resection chips thus permitting continuous visualisation of tissue effect

bull Cutting power and coagulation is better due to plasma effect

bull Vision during resection is not disturbed

bull A vaporizing electrode may prevent significant blood loss during myoma resection by sealing blood vessels as the tissue is vaporized13

See and treat

bull Option to treat benign pathology in the same sitting

bull Saves time

bull Avoids return visits

bull Reduces the anxiety of pt between the diagnosis and treatment

bull Bipolar can be used with smaller diameter hysteroscopeNo dilatation is required

Electrical circuit

Monopolar

The entire patient is involed in the circuit

Greater chances of current diversion to undesirable locations

Bipolar circuit

Current flows between two electrodes the circuit is closed by placing tissue between two electrodes

less chance of diversion

Types of electrode

bull Spring twizzle and ball electrode

bull Spring tip for hemostatic vaporization large areas

bull Ball tip for precise vaporization

bull Twizzle tip for hemostatic resection and morcellation of tissue

bull Cutting loop similar to traditional resectoscopy

bull It allows vaporisation of tissue

bull Cuts and dessicates the tissue

bull Instantaneous tissue vaporization eliminates resection chips thus permitting continuous visualisation of tissue effect

bull Cutting power and coagulation is better due to plasma effect

bull Vision during resection is not disturbed

bull A vaporizing electrode may prevent significant blood loss during myoma resection by sealing blood vessels as the tissue is vaporized13

Electrical circuit

Monopolar

The entire patient is involed in the circuit

Greater chances of current diversion to undesirable locations

Bipolar circuit

Current flows between two electrodes the circuit is closed by placing tissue between two electrodes

less chance of diversion

Types of electrode

bull Spring twizzle and ball electrode

bull Spring tip for hemostatic vaporization large areas

bull Ball tip for precise vaporization

bull Twizzle tip for hemostatic resection and morcellation of tissue

bull Cutting loop similar to traditional resectoscopy

bull It allows vaporisation of tissue

bull Cuts and dessicates the tissue

bull Instantaneous tissue vaporization eliminates resection chips thus permitting continuous visualisation of tissue effect

bull Cutting power and coagulation is better due to plasma effect

bull Vision during resection is not disturbed

bull A vaporizing electrode may prevent significant blood loss during myoma resection by sealing blood vessels as the tissue is vaporized13

Types of electrode

bull Spring twizzle and ball electrode

bull Spring tip for hemostatic vaporization large areas

bull Ball tip for precise vaporization

bull Twizzle tip for hemostatic resection and morcellation of tissue

bull Cutting loop similar to traditional resectoscopy

bull It allows vaporisation of tissue

bull Cuts and dessicates the tissue

bull Instantaneous tissue vaporization eliminates resection chips thus permitting continuous visualisation of tissue effect

bull Cutting power and coagulation is better due to plasma effect

bull Vision during resection is not disturbed

bull A vaporizing electrode may prevent significant blood loss during myoma resection by sealing blood vessels as the tissue is vaporized13

bull It allows vaporisation of tissue

bull Cuts and dessicates the tissue

bull Instantaneous tissue vaporization eliminates resection chips thus permitting continuous visualisation of tissue effect

bull Cutting power and coagulation is better due to plasma effect

bull Vision during resection is not disturbed

bull A vaporizing electrode may prevent significant blood loss during myoma resection by sealing blood vessels as the tissue is vaporized13

Uses

bull Removal of submucous fibroids

bull Transection of intrauterine septa

bull Removal of polyps

bull Endometrial Ablation

bull Transection of intrauterine adhesions

Complications of Monopolar resectoscope

bull Active electrode injury-perforation of uterus bowelbladder

bull Other vascualr structure

bull Current Diversion-burns to cervixvagina or vulvabull Damage of electrode insulation

bull Loss of contact with between external sheath and cervix ndashburns

bull Direct coupling of current-if tissue is stuck

bull Genital tract injuries have occurred as a result of current diversion Vilos and colleagues

Distension media

bull For monopolar-use electrolyte free distension media like sorbitolglycine or mannitol

bull Bipolar resectoscopic are generally designed that even in the electrolyte rich media like normal slaine the circuit is completed

bull Biggest advantageThe risk of hyponatremia is obviated Hyponatremiandash cerebral edema caused by Glycine ndashdeath

bull In Bipolar-normal saline used has ion concentrations similar to human

plasma which reduces electrolyte changes and hyponatremia

bull Fluid deficits must still be monitored so they do not exceed 2000 mL

bull A randomized trial comparing monopolar electrodes using glycine15 with two different types of bipolar electrodes (TCRis Versapoint) using saline in hysteroscopic surgery(Berg A SandvikL Langebrekke A Istre O)

bull Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium Irrigant consumption was significantly higher in the two bipolar groups without any side effects during or after the procedure

Complications of Monopolar resectoscope

bull Active electrode injury-perforation of uterus bowelbladder

bull Other vascualr structure

bull Current Diversion-burns to cervixvagina or vulvabull Damage of electrode insulation

bull Loss of contact with between external sheath and cervix ndashburns

bull Direct coupling of current-if tissue is stuck

bull Genital tract injuries have occurred as a result of current diversion Vilos and colleagues

Distension media

bull For monopolar-use electrolyte free distension media like sorbitolglycine or mannitol

bull Bipolar resectoscopic are generally designed that even in the electrolyte rich media like normal slaine the circuit is completed

bull Biggest advantageThe risk of hyponatremia is obviated Hyponatremiandash cerebral edema caused by Glycine ndashdeath

bull In Bipolar-normal saline used has ion concentrations similar to human

plasma which reduces electrolyte changes and hyponatremia

bull Fluid deficits must still be monitored so they do not exceed 2000 mL

bull A randomized trial comparing monopolar electrodes using glycine15 with two different types of bipolar electrodes (TCRis Versapoint) using saline in hysteroscopic surgery(Berg A SandvikL Langebrekke A Istre O)

bull Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium Irrigant consumption was significantly higher in the two bipolar groups without any side effects during or after the procedure

Distension media

bull For monopolar-use electrolyte free distension media like sorbitolglycine or mannitol

bull Bipolar resectoscopic are generally designed that even in the electrolyte rich media like normal slaine the circuit is completed

bull Biggest advantageThe risk of hyponatremia is obviated Hyponatremiandash cerebral edema caused by Glycine ndashdeath

bull In Bipolar-normal saline used has ion concentrations similar to human

plasma which reduces electrolyte changes and hyponatremia

bull Fluid deficits must still be monitored so they do not exceed 2000 mL

bull A randomized trial comparing monopolar electrodes using glycine15 with two different types of bipolar electrodes (TCRis Versapoint) using saline in hysteroscopic surgery(Berg A SandvikL Langebrekke A Istre O)

bull Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium Irrigant consumption was significantly higher in the two bipolar groups without any side effects during or after the procedure

bull A randomized trial comparing monopolar electrodes using glycine15 with two different types of bipolar electrodes (TCRis Versapoint) using saline in hysteroscopic surgery(Berg A SandvikL Langebrekke A Istre O)

bull Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium Irrigant consumption was significantly higher in the two bipolar groups without any side effects during or after the procedure

bull Case-Control Study of Complications Associated With Bipolar and Monopolar Hysteroscopic Operations

bull Raz Bahar MD Michal Shimonovitz BMedSc Avi Benshushan Asher Shushan(The Journal of Minimally Invasive Gynecology Volume 20 Issue 3 Page 376-380)

bull The bipolar hysteroscopic system has eliminated the need to use hypotonic solutions as irrigation medium with its life-threatening complications When limiting normal saline solution to 2 L no serious complications associated with irrigation medium are expected Therefore we believe that when available the bipolar system should be preferred

Comparision of Monopolar and Bipolar resection of myoma (Romer T)bull Preferred Indications

bull Myoma Grade 2 and large myoma(gt4cm)

bull Advantage

bull Avoidance of TUR syndrome

bull Less complications

bull raerly second surgery

bull Results 60 after first surgery with monopolar95 with bipolar

conclusions

bull Bipolar has biggest advantage that it can be done with NS or RL without the fear of life treatening complication like cerebral edema

bull The main evolution with Bipolar is shifting from inpatient procedures to the office leading to saving of medical costs and making see and treat facility

bull Excellent hemostasis in vapour cut mode

bull Total vaporisation of myoma avoids the process of removing the chips from field of vision

Thankyou

Comparision of Monopolar and Bipolar resection of myoma (Romer T)bull Preferred Indications

bull Myoma Grade 2 and large myoma(gt4cm)

bull Advantage

bull Avoidance of TUR syndrome

bull Less complications

bull raerly second surgery

bull Results 60 after first surgery with monopolar95 with bipolar

conclusions

bull Bipolar has biggest advantage that it can be done with NS or RL without the fear of life treatening complication like cerebral edema

bull The main evolution with Bipolar is shifting from inpatient procedures to the office leading to saving of medical costs and making see and treat facility

bull Excellent hemostasis in vapour cut mode

bull Total vaporisation of myoma avoids the process of removing the chips from field of vision

Thankyou

conclusions

bull Bipolar has biggest advantage that it can be done with NS or RL without the fear of life treatening complication like cerebral edema

bull The main evolution with Bipolar is shifting from inpatient procedures to the office leading to saving of medical costs and making see and treat facility

bull Excellent hemostasis in vapour cut mode

bull Total vaporisation of myoma avoids the process of removing the chips from field of vision

Thankyou

Thankyou