Why Cautery:
The use of cautery dates back to prehistoric times when hot stones were used to stop bleeding. Still, in modern days, cautery is paramount, and an absolutely essential item to have in the majority of ophthalmic procedures.
Hemostasis remains the most important role of cautery. Without hemostasis, we run the risk of bleeds leading to the worst case scenario of a retrobulbar hematoma and blindness. Hemostasis allows for a safer and more favorable outcome. But besides hemostasis, cautery can be used for other purposes. We use it commonly in ophthalmology to induce punctal stenosis for patients with dry eyes. We use it to close conjunctival incisions. We use it as a surgical marker.
What You Need to Know:
Heat is generated through an electrical current and flows to a metal tip to coagulate blood vessels and stop bleeding. Electrocautery comes in the form of monopolar or bipolar. With monopolar electrocautery, the current is applied through a handheld active electrode and travels back to the generator through an inactive electrode attached to the patient (the grounding pad), so the patient is part of the electrical circuit. The inactive electrode is typically placed on a large area of the body to avoid heat conduction.
With bipolar electrocautery, the current is passed between one forceps tip to the other, and a limited amount of tissue is cauterized in between. The current is spread more with monopolar electrocautery, there is more tissue damage, and recovery of the tissue takes a bit longer. Bipolar cautery allows for more precise delivery of the heat. Lateral thermal damage is greater with unipolar cautery than bipolar cautery.
For these reasons, I use bipolar cautery more often, but many use monopolar cautery because this method tends to decrease surgical time with the capability to cut and coagulate with the same instrument.
Below is a discussion and comparison of a variety of cautery units.
Wet-Field Hemostatic Coagulator - Beaver Visitec
Wet-Field Hemostatic Coagulator
Beaver Visitec
This unit is designed to provide precise hemostasis with reduced peripheral tissue trauma. Controlled radiofrequency diathermy delivers targeted coagulation. The box weighs only 4 lbs. and requires 100 – 240 VAC, 65 VA, 50/60 Hz. There are a variety of tips, including eraser instruments, forceps and cables.
Wet-Field Osher ThermoDot Marker - Beaver Visitec
Wet-Field Osher ThermoDot Marker
Beaver Visitec
This bipolar instrument is designed to create an ink-free fine dot on the eye that can be used as a precise reference point for a variety of ocular procedures, including toric intraocular lens implantation. As opposed to a traditional surgical marking pen, this mark will not smear and will last the duration of the surgery.
Force Triad™ Energy Platform - Covidien
Force Triad™ Energy Platform
Covidien
The ForceTriad energy platform provides cutting and coagulation, bipolar functionality and vessel sealing in one generator. It includes Valleylab mode for electrosurgery. The company offers the Valleylab Exchange Software Update System to update your current system.
Force FX™ Electrosurgical Generator - ValleyLab
Force FX™ Electrosurgical Generator C with Instant Response Technology
ValleyLab
The Force FX is designed to work at lower power settings to minimize the risk of tissue damage. It can cut through different tissues with a PER of 98 in cut, and is capable of automatically adjusting to tissue changes. This maintains power delivery and minimizes drag.
Force EZ Electrosurgical Generator - ValleyLab
Force EZ Electrosurgical Generator C with Instant Response Technology
ValleyLab
The Force EZ unit is designed for most monopolar and bipolar procedures with a PER of 97 in cut. It also adjusts automatically, like the Force FX.
SurgiStat II - ValleyLab
SurgiStat Electrosurgical Generator II
The SurgiStat is a compact unit designed for general electrosurgery procedures. Simples to use, it offers both monopolar and bipolar outputs.
20-Watt Bipolar Coagulator - Kirwan
20-Watt Bipolar Coagulator
Kirwan
With 20 watts of power, this generator is well suited for ophthalmology use. It offers adjustable settings and provides an audible tone during output power activation. With touchpad controls and footswitch activation, it’s simple to use as well.
TIPS
As a side note, below are some of my favorite bipolar cautery tips that can be used with any of the above units. The products pictured below are manufactured by Kirwan Surgical. I have used many, and my favorites so far are the coated, non-stick forceps tips.
Bayonet: I use these tips for dacryocystorhinostomies, optic nerve sheath fenestrations, orbital tumor excision, and any other procedure where deep cautery may be needed.
Semkin: These are my favorite forceps tips for direct browplasties.
Jewelers: These are my most commonly used forceps tips. I use these for chalazia, lid lesions, blepharoplasties, ptosis repairs, enucleations, Mohs’ reconstructions, etc. They come in a variety of sizes and styles.
Colorado Needle
Stryker
This needle is a monopolar electrode with a sharp tungsten tip for soft tissue dissection. It operates at high temperatures with insulation designed to prevent unwanted tissue damage.
Peak PlasmaBlade Device - Medtronic
Peak PlasmaBlade Device
Medtronic
This unit is powered by the PULSAR II Generator and is unique in that it uses radiofrequency energy. It is a disposable, soft tissue dissection instrument that uses brief, high-frequency pulses of radiofrequency energy to induce electrical plasma along the edge of a 12.5 um thin, 99.5% insulated electrode. Radiofrequency reduces thermal injury depth while maintaining cutting effectiveness and hemostatic ability, even in liquefied tissue or blood. This device operates at lower temperatures than traditional electrosurgical technology (40 – 170 degrees Celcius vs. 200 – 350 degrees Celcius).
One last side note that I will mention is the hot temperature disposable cautery device. These are useful for clinic procedures or in the emergency room where single use is helpful and transportation of large units with cords and foot pedals is not feasible.
Accu-Temp® Cauteries - Beaver Visitec
Accu-Temp® Cauteries
Beaver Visitec
Accu-Temp Cauteries are single use cauteries with a one-year shelf life. They are available in a variety of tip styles.
In summary, bipolar electrocautery is a very precise way to deliver heat to tissues to stop bleeding during procedures or after trauma while causing minimal tissue damage. The units discussed above all offer their own advantages and can be used in a variety of capacities.