the foot pedal — that lets you alter how frequently per minute the ener-
gy fires. That lets you fire more rapidly without resorting to the continu-
ous waveform of the cut setting. Properly regulating the waveform lets
you use the lowest power setting possible, which, again, should be the
goal.
3
Understand that technique is as important as choosing the
right settings. You get one type of tissue effect when you actu-
ally touch the tissue; you get another if you merely hover near
the tissue. For example, if you're trying to make a skin incision, you
should use the cut button, but you shouldn't touch the tissue.
Touching the tissue heats it up too fast and also results in some coag-
ulation. Ultimately, you want the tissue to stay healthy and be able to
heal, so you don't want it to be fried. Keeping the temperature a little
lower makes a nice vapor pocket and provides a clean cut.
Another example that almost all general surgeons have to deal with is
removing an inflamed gallbladder from the liver bed at the end of a
laparoscopic cholecystectomy. You want that superficial very hot tem-
perature to seal off the liver bed, but if you have too much tissue con-
tact, you can actually pull off the clot.
The best bet is to maintain a little distance from the tissue and use an
arcing effect. It's about knowing how the energy is working, and about
using the right technique. Instead, the tendency I've seen is for people
to simply turn the power way up. You might want to turn it up a little,
because we want the temperature of the tissue to be hotter, but you
don't need to turn it up much if you're using the right technique. You
can learn technique partly by practicing, but also by learning to under-
stand the mechanisms behind tissue effect. Unfortunately, that's some-
thing that's really been missing from the surgical curriculum.
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