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Ultrasonic scalpel (3) Operation skills

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Update time : 2023-11-15 15:42:00
The four major functions of ultrasonic scalpel: cutting, coagulation, clamping, and separation. Among them, separation is second only to cutting. Only when the anatomical gap is clearly separated can the ultrasonic knife be used for cutting. Blindly inserting the ultrasonic knife into the tissue for cutting is unsafe.
1. Extension action
The blade of the ultrasonic scalpel is in the shape of a blood vessel forceps, so it can be used as a blood vessel forceps for separation. The spreading action is an extremely important action. The more stretching movements are used, the less time wasted changing instruments. It also makes the anatomy clearer and the surgery safer.
The purpose of distraction can be to create a cutting gap for the ultrasonic scalpel, or it can be used to free the sheath of blood vessels and free the gap between lymph nodes and blood vessels. It can separate blood vessels and separate bronchi.
Because the front end of the ultrasonic scalpel blade is blunt, it is safer than sharp vascular forceps. Moreover, the temperature of the ultrasonic scalpel head is not high when it is not working. At present, no cases of thermal damage caused by the ultrasonic scalpel when it is not working have been found.
The purpose of stretching is to reveal the gap, so while stretching, you can add a little upward and outward movement.
Continuously use the spreading action to provide a clear cutting gap for the ultrasonic knife, rather than directly inserting the ultrasonic knife into the gap for cutting.
The ultrasonic scalpel opens and lifts the vascular sheath, making it easier and faster to free the vascular sheath.
When freeing the gap, pay attention to the coordination of the suction device. The suction device and the ultrasonic scalpel cooperate with each other and can be used to open various tunnels. For example, tunnels for pulmonary fissures, lymph node dissection using the tunnel method, etc.
During laparoscopic right pneumonectomy, the ultrasonic scalpel is freeing the right pulmonary artery trunk, which shows that it is safe and does not cause thermal damage in the non-working state.
(2) Pushing action
The front head of the ultrasonic scalpel is blunt, and its non-working state has a low temperature, so the blade can be used for pushing, which is a blunt separation method. In fact, the push-pull separation action is generally performed by the suction device. However, in many cases, the suction device is responsible for the important task of exposure and cannot be removed. At this time, using an ultrasonic scalpel to perform blunt separation can save a lot of time in changing instruments. The right hand is used as a mobile hand to separate tissues, making the operation more comfortable.
As long as the tissue is loose and has gaps, pushing can be used. When pushing, pay attention to maintaining a certain tension in the tissue gap. The amplitude and strength of pushing need to be determined according to the specific conditions during the operation. Of course, this is also related to the surgeon's personal habits.
Beginners should move gently and gently, with smaller amplitudes. Sharp pushing can cause tissue tearing and bleeding. During the push-and-pull separation process, if you encounter cord-like tissue, you can use an ultrasonic scalpel to cut it off and continue moving forward.
It has been proven to be safe for the ultrasonic scalpel to contact blood vessels when it is not in action. When using the super knife, be careful not to clamp too much tissue at one time, and do not cut for more than 20 seconds, otherwise the temperature of the cutter head will be too high.
When cleaning lymph nodes, the aspirator is responsible for the exposure work, and the ultrasonic scalpel frees up the gap through pushing and pushing separation, providing a safe space for the next cutting action of the ultrasonic scalpel. What is pushed underneath the ultrasound scalpel is the vena cava.
Use an ultrasonic scalpel to push the lymph nodes farther away to make the tissue gaps clearer and increase the operating space. If the lymph nodes are too dense to be pushed, an ultrasonic scalpel will be used to close the lymph nodes and cut them off.
The aspirator stirs up the azygos vein, and the ultrasonic scalpel bluntly peels off the lymphoid tissue, and then further cuts it after identification. Of course, it may be better to grasp the lymph nodes here. Some people believe that lymph node dissection should be performed without grasping, which can reduce the chance of metastasis.
The ultrasonic scalpel pushes the lymphatic tissue upward, and there is also a bit of shaving action here. Of course, when faced with this situation, expansion movements can also be used to make the anatomy clearer.
(3) Provoke action
The working surface of the blade of the ultrasonic scalpel is relatively small, so it is often used to lift tissue and then cut it. Because the hemostatic cutting of ultrasonic scalpel is completed in one step, and the cutting is also part of the sharp separation, many actions are difficult to completely classify.
The lifting action is the basic operation of the ultrasonic scalpel. Use the thin blade of the ultrasonic scalpel to lift the tissue, and then continue to cut while picking. The core idea is to open the gap between the cut tissue and normal tissue to prevent accidental injury. In addition, applying pick force while cutting will be more helpful in cutting the tissue.
The provoking action is very similar to that of an electrocoagulation hook, which can lift the sheath of blood vessels, diagonally split membranous tissue, and clearly separated tissue gaps. In other words, provoke any tissue you want to cut off.
The four major functions of ultrasonic scalpel: cutting, coagulation, clamping, and separation. Continuing from the previous article, this article introduces the cutting, coagulation and clamping functions of the ultrasonic scalpel.
1. Condensation
The coagulation and hemostasis function of ultrasonic scalpel is powerful, and its hemostatic function is better than other energy devices. Ultrasonic scalpel can stop bleeding while cutting off tissue, achieving cutting and hemostasis in one step. Ultrasound scalpel can also be used alone to stop bleeding at bleeding points. When using ultrasonic scalpel to coagulate and stop bleeding, there are the following points to note:
1. Pay attention to maintaining a tension-free state when handling blood vessels.
When using ultrasonic scalpel to cut blood vessels, care must be taken to keep the blood vessels in a tension-free state. Because if there is tension when cutting the blood vessel, it may cause the blood vessel to be cut in half and cause tearing. However, the stagnant thrombus is not completely formed at this time, causing bleeding.
Since the cutting effect of the ultrasonic knife comes from mechanical vibration, it is often used to trim threads. If it is a reusable cutter head, it is recommended not to use the ultrasonic cutter head to cut the thread, so as not to reduce the service life of the cutter head.
2. For thicker blood vessels, coagulate first and then break them
You can first use the electrocoagulation function of the ultrasonic scalpel to coagulate both ends of the blood vessel for a while, and then cut it in the middle. This can increase the coagulation thrombus in the blood vessel and increase the reliability of hemostasis.
3. Ultrasonic scalpel can be used to stop bleeding at bleeding points
The bleeding tissue is picked up with an ultrasonic scalpel and then electrocoagulated. Note that the blade of the ultrasonic scalpel is blunt, so it may be difficult to clamp delicate places and requires practice. After clamping the bleeding tissue, slightly lift the ultrasonic scalpel blade away from large blood vessels and bronchial walls to prevent accidental injury.
2. Cutting
The ultrasonic scalpel relies on high-frequency mechanical vibration to cut and stop bleeding. Therefore, many surgeons like to add a little tension while cutting, which will speed up the tissue cutting. Moreover, the faster the tissue cutting speed, the lower the temperature of the cutting head. (This technique is only suitable for tissue without major blood vessels. As mentioned above, the cutting of blood vessels must be maintained without tension.)
This cutting and tearing action actually includes four major functions: clamping, blunt separation, cutting, and hemostasis. The amplitude and strength of the action vary depending on the surgeon's habits. Beginners should relax their attention span and don’t make it too big.
Because of the addition of blunt separation action, tissue gaps will be more easily exposed. Note that the force of the ultrasonic scalpel should be directed away from and away from important blood vessels and other easily damaged tissues, and to facilitate tissue separation.
The ultrasonic knife clamps the loose tissue at the bottom of the lymph node, and uses cutting + tension to remove the lymph node. This maneuver is often used to remove lymph nodes, including removal of epibronchial lymph nodes.
The ultrasonic scalpel picks up the bottom of the lymph node and then removes it. Because the temperature of the ultrasonic scalpel blade is lower than that of the bipolar electrocoagulation hemostat, the hemostatic effect is better, so the ultrasonic scalpel is more suitable for this action.
Ultrasound is also often used to cut small amounts of lung tissue, such as underdeveloped lung fissures.
3. Clamping
The clamping function of the ultrasonic scalpel is often completed simultaneously with cutting, coagulation, and separation.
Generally speaking, try to use the first two-thirds of the blade when holding the ultrasonic scalpel. In fact, for unimportant tissues, you can clamp a large amount and cut quickly; for delicate operations, you need to be careful and careful, such as a chicken pecking at rice, and use the sharpest part of the knife head to gently bite up a small amount of tissue. If operated carefully, the ultrasonic scalpel can perform delicate operations like an electric hook.
Beginners who use ultrasonic scalpel should start with a small amount of tissue, which will help them practice their operational finesse. Practice the precision of clamping on unimportant tissues. Once you are proficient in the operation, you will gradually begin to perform delicate operations such as freeing blood vessels and removing lymph nodes next to blood vessels.
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