Bright beams of light shoot out of handheld devices and slice through human tissue with ease. It sounds like something out of Star Wars, but the little lightsabers being used in operating rooms around the country are actually plasma devices designed to cut and coagulate tissue without the harsh effects associated with traditional electrosurgery.
The goal of these new devices is to deliver the precise cut of a scalpel and effective coagulation with minimal lateral thermal tissue damage. Unlike other electrosurgical devices, these tools use plasma a highly energized gas to gently slice tissue and seal oozing spots.
Is plasma right for you? Here's your primer on the science behind these devices and how they could impact your ORs.
Quick primer on plasma
When the term plasma is mentioned in medicine, most people think of a component found in blood. However, the plasma used in these cutting and sealing devices is actually referring to something more commonly found among the stars and planets than in your patients.
If you can't remember back to the days of high school science class, here's a refresher. Plasma is considered the fourth state of matter in the universe, after gas, liquid and solid, says Vangie Dennis, BSN, RN, CNOR, CMLSO, director of patient care services at ASC Emory Health System in Atlanta, Ga.
To create plasma, a form of energy is applied to a pressurized gas, which causes it to lose its electrons and become highly energized. This gives plasma unique properties, including rapid energy transfer, which is why it works well for cutting or coagulating tissue. Argon and helium are 2 common gases used in plasma formation.
When it comes to how it's used in surgery, each plasma system operates a little differently. "They have different applications and the energy is created in a different way, depending on the model," says Ms. Dennis. However, the important thing to know is that the goal of plasma devices is the same precise cutting and coagulation with minimal collateral tissue damage.
The plasma scalpel Joshua Cooper, MD, works with is a monopolar device that uses pulsed radiofrequency waveforms to emit bursts of plasma from the "scalpel's" tip. His system is comprised of 3 components a generator, a single-use handheld device and a grounding pad.
To operate the scalpel, you first turn on the "toaster-sized" generator, says Dr. Cooper, the director of cardiac electrophysiology at Temple University. This generator delivers the radiofrequency energy that creates the plasma pulses in the single-use handheld device. "It's like a pen," says Dr. Cooper. "In fact, I hold it just like a pen."
The energy pulses surround the device's electrode tip which is highly insulated compared to traditional electrosurgical tools helping to protect against thermal injury. When the pulses of plasma touch the tissue, they generate a low-temperature heat that cuts or coagulates, depending on which button is pressed on the handpiece. Since this system is monopolar and delivers electrically charged plasma, Dr. Cooper notes that a grounding pad must be attached to the patient.
But not all plasma systems work this way. Other options include a bipolar system that delivers an electrically neutral plasma beam for open or laparoscopic surgery, which Ms. Dennis says she used at her previous facility.
While this model also requires a console and a single-use handheld device, it instead works by passing low-voltage electricity between 2 internal electrodes to ionize argon. This creates electrically neutral plasma, says Ms. Dennis, which is then emitted as a beam from the tip of the handheld tool.
When this beam contacts tissue, it first transfers its heat quickly to cut and/or seal tissue, depending on the handpiece and setting the surgeon selects. Additionally, the physical force of the plasma beam actually pushes aside blood and other fluids to provide a clear and clean surface for cutting or coagulation, says Ms. Dennis.
Compared to Dr. Cooper's scalpel, the plasma in these bipolar devices generates a higher temperature, but they do not pass an electric current through the patient. This means you don't use a grounding pad, and it improves patient safety, says Ms. Dennis. "You don't have a risk of insulation failure, direct coupling or capacitive coupling," she says.
How low can you go?
Though every system has a unique, patented way of creating plasma and applying its energy to tissue, they all minimize lateral thermal spread, which can improve wound healing and reduce infection. "The two main purposes of any electrosurgical device are to cut or coagulate tissue," says Dr. Cooper. "With the plasma and especially with the cut function the major difference is that it does this at a lower temperature."
Because Dr. Cooper's scalpel uses pulses of plasma, it cleanly cuts through tissue at a low temperature, reducing tissue necrosis and scarring when compared to other electrosurgery. Some research suggests that while traditional electrosurgery instruments can cause thermal injury depths of up to 1.5 mm, a plasma scalpel can create values of only 250 ?m. "It lets you cut sensitive tissue without a heat burn injury, which is better for the patient," says Dr. Cooper.
In Dr. Cooper's specialty, the plasma is essential when working on patients with pacemakers or defibrillators, since the leads on these devices melt and cause complications when traditional electrosurgery is used. While electrosurgery reaches temperatures of 250 ?C to 350 ?C, Dr. Cooper says his plasma scalpel tends to hover between 40 ?C and 170 ?C, depending on if it's cutting or coagulating. "In these surgeries, we use cautery tools to dissect between sensitive leads," he says. "That's where the plasma has been so useful for me."
Ms. Dennis notes that while the plasma in her device produces higher temperatures, its swift transfer of kinetic energy and physical force leaves less than 0.5 mm of lateral thermal spread to tissue. She says that surface temperatures of tissue that's been coagulated with the plasma beam are around 100 ?C, letting the device precisely vaporize tissue with minimal collateral damage. Plus, Ms. Dennis says, the device uses circulating coolant to keep the handpiece and tip at room temperature. "It has a high temperature initially, but it gets cool extremely fast," she says.
This gentle cutting and coagulating action makes plasma a useful adjunct technology across specialties, says Ms. Dennis. She notes that her facility has used plasma coagulation for liver resections and breast reductions, though it's gentle approach makes it perfect for cases with a lot of bleeding, or operations near sensitive structures, including orthopedics, spinal cases, gynecology, urology, open general surgery and laparoscopy. "It works for virtually anything," she says.
Plasma's gentle cutting and coagulation actions are also coupled with several other benefits to enhance patient safety and outcomes. Plasma delivers more precise cuts than electrosurgery or even metal scalpels, further improving wound strength and scarring. For example, one company cites a study showing its plasma scalpel causes only 0.1 mm of injury to surrounding tissue, compared with 0.8 mm caused by a traditional steel device.
Along with their precision, plasma scalpels can also help reduce bleeding by creating a thin, flexible seal in tissue as they cut, says Dr. Cooper. "For a surgeon who uses this to slice through skin instead of a metal scalpel or standard cautery device, you can do so with less blood loss," he says.
There are other patient safety aspects to consider as well, says Ms. Dennis. She notes neutral, bipolar plasma models don't spark like other electrosurgical devices, making them less likely to cause an OR fire. Plus, these designs also use a low-flow gas rate of 0.4 liters per minute, which reduces the risk of embolism and over-pressurization in laparoscopic patients.
Your staff also benefits from plasma since these devices generate much less smoke compared to traditional electrosurgery though Ms. Dennis adds you still must use an evacuator. "It does generate smoke, but it's less," she says. "It's more equivalent to a harmonic or ultrasonic scalpel."
Despite all of the advantages, there is one big reason plasma isn't in more ORs benefit versus cost. For example, in a study looking at pediatric patients undergoing an adenotonsillectomy, researchers found that using traditional monopolar cautery resulted in similar outcomes to a plasma scalpel. However, the overall average cost of using monopolar cautery was around $30 while the plasma scalpel's costs were closer to $250 (osmag.net/4TRfEu).
"The cost of the disposable element, which is the handheld device, is much more expensive than standard cautery equipment," says Dr. Cooper, who adds his plasma scalpel's handpiece can cost somewhere between $250 and $350. "That's the main disadvantage."
Better outcomes, but at a cost
While plasma devices all operate a little differently, the high price tags are pretty consistent among models. Ms. Dennis notes when she used the device, costs could top $500 for the handheld single-use device, though the manufacturer is attempting to lower the price. The cost keeps the technology out of many ORs, says Ms. Dennis, despite the fact that its gentle and precise actions would benefit patients across specialties.
"Would it be great for tonsillectomy? Absolutely," says Ms. Dennis. "But who would pay $500 to use it to do a tonsillectomy when your reimbursement for the whole procedure is only $500? In health care, it's all about finding a balance. Plasma technology is very cool. Maybe one day it will be cost-effective."