Special Article

History of Power Sources in Endoscopic Surgery

Christopher Sutton, MA (Cantab), MB, BChir, FRCOG*, and
Jason Abbott, BMed (Hons), FRANZCOG, FRCOG, PhD
From the Departments of Gynaecological Surgery, Faculty of Health and Medical Sciences, University of Surrey, Guildford, England (Dr. Sutton), and
School of Women’s and Children’s Health, University of New South Wales, Sydney, Australia (Dr. Abbott).

ABSTRACT The history of energy sources used in surgery is inextricably linked to the history of electricity. Milestones include identifi-
cation of safe electrical waveforms that can be used in the human body, patient isolation to prevent alternate-site burns, bipolar
energy sources to negate capacitance injuries, laser energy, and the combination vessel sealing devices commonly used today.
Engineering efforts to eliminate many of the hazards of electrosurgery are critical to how we practice modern gynecologic
surgery. The introduction of bipolar instruments, increasing the safety of monopolar electrosurgery by not using hybrid tro-
cars, and introduction of active shielding of the instruments from stray radiofrequency energy using intelligent secondary con-
ductors have led to the re-emergence of electrosurgery as the universal surgical energy source. The low ongoing costs and the
presence of electrosurgical generators in all hospitals readily enables electrosurgery to be the mainstay. Expensive lasers are
confined to specialized centers, where they continue to be used, but for a long while filled a gap created by complications of
electrosurgery. Sophisticated power sources continue to be introduced and include the ultrasonic scalpel, plasma surgery, and
various devices for sealing vessels, all of which have advantages and disadvantages that are recognized as they begin to be
subjected to scientific validation in randomized trials. Journal of Minimally Invasive Gynecology (2013) 20, 271–278
Ó 2013 AAGL. All rights reserved.
Keywords: Electrosurgery; History of hysteroscopy; History of laparoscopy; Laser; Plasma surgery; Ultrasonic (harmonic) scalpel

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In 1925, use of energy entered the field of gynecologic In hysteroscopic surgery, progression of electrosurgery
surgery when a power source was first used during hystero- included the urologic resectoscope for removal of submu-
scopy to fulgurate the pedicle of a pedunculated myoma. cous myomas and then endometrial ablation using a neody-
Since this first procedure, surgeons have had to overcome nium-doped yttrium-aluminum-garnet (Nd:YAG) laser as
many of the issues associated with electrosurgery. The Bovie the energy source followed by an electrosurgical loop or roll-
electrosurgical generator provided a turning point in surgical erball. Early attempts at electrosurgical laparoscopy were
care and has become so commonplace that the term ‘‘bovy- catastrophic because of the hazards of using radiofrequency
ing’’ is synonymous with electrosurgical procedures. energy with oxygen as the distention medium, and later be-
cause of hazards of injury to bowel from insulation defects
and direct and capacitative coupling. Laser energy was
The authors have no commercial, proprietary, or financial interest in the much more precise and was not associated with many
products or companies described in this article.
Corresponding author: Prof. Christopher Sutton, MA (Cantab), MB, BChir,
of the hazards of electrosurgery, but required considerable
FRCOG, Department of Gynaecological Surgery, Faculty of Health and experience and skill and was expensive to establish and
Medical Sciences, University of Surrey, Gunners Farm, Stringers Common, maintain.
Jacobs Well, Guildford GU4 7PR, UK. The history of electrosurgery is important because under-
E-mail: chrislasersutton1@[Link] standing why changes occurred reflects essential patient
Submitted October 5, 2012. Accepted for publication March 5, 2013. safety and has enabled contemporary surgeons to use instru-
Available at [Link] and [Link] ments with a greater margin of safety. This also has its
1553-4650/$ - see front matter Ó 2013 AAGL. All rights reserved.
[Link]
272 Journal of Minimally Invasive Gynecology, Vol 20, No 3, May/June 2013

drawbacks in that not understanding the physics and power perimented with magnetic fields, and this culminated in his
of the instrument may be detrimental to patient health. Ignor- 1831 documentation of electromagnetic induction, which re-
ing history risks reverting to mistakes already made, recog- sulted in the building of the electric motor [7]. His work en-
nized, and in many instances resolved. abled electrical energy to be reliably harnessed and stored
and provided the introduction of an electrosurgical generator.
Methods The French physicist Becquerel reported the first use of
electrosurgery in the early 19th century when he described
This review included a search of electronic resources, e.g., a non-alternating current to heat wire, which when applied
Medline, PubMed, CINAHL, the Cochrane Library, Current to tissue had a hemostatic effect, i.e., cauterization [8].
Contents, and EMBASE. The Medical Subject Headings This was an indirect use of electricity because the problem
(MeSH) including all subheadings and keywords used in- of electrical energy directly passing through the patient
cluded ‘‘Electricity and history,’’ ‘‘Electrocoagulation,’’ ‘‘Elec- had been noted to lead to the galvanic phenomena of muscle
trosurgery,’’ ‘‘Energy source,’’ and ‘‘Laser.’’ Articles were contraction, interference with cardiac function, and likely
screened for historical facts about electrosurgery and were death. In 1891, the French biophysicist D’Arsonoval demon-
manually cross-referenced when appropriate. Web searches strated that it was possible to pass high-frequency (.20
were performed using educational sources if appropriate. kHz) alternating current through the body without causing
these adverse effects, including death [9]. The passage of
History of Electricity and Its Importance for high-frequency alternating current was noted to elevate tis-
Electrosurgery sue temperature without necessarily leading to burns or pain.
William Clark [10] is credited with bringing electrosur-
The use of electricity in medicine is rooted in ancient times, gery to the United States after studying the effect of heat
and although the first Greek and Roman healers applied in the treatment of neoplasms. He published his findings in
shocks from electric rays in an attempt to heal a host of mal- 1931; however, his equipment was considered too bulky to
adies, they were unable to provide an explanation as to how be practical. He saw the usefulness of electrosurgery as
this worked. The recognition of electricity by Benjamin near universal and made the prophetic statement, ‘‘I predict
Franklin in the 18th century and his theory that this phenom- that electro-surgery will continue to grow in usefulness, in-
enon could be used in medicine led to a series of treatments deed to be found indispensable to every surgical procedure.’’
and experiments in Europe and North America, with mixed The modern electrosurgical generator is attributed to the
and inconsistent results. The German Professor Johann work of two Americans, physicist William T. Bovie and neu-
Kruger [1] suggested that electricity may be used in cases of rosurgeon Harvey Cushing, who applied all of the knowl-
neurologic impairment such as paralysis, and he and student edge to date relating to electrical energy, high-frequency
Kratzenstein [2] studied and presented to the Royal Society alternating current, and the application of time, power, and
findings of experiments in patients who had experienced electrode size to develop their electrosurgical generator in
stroke, although they admitted that the outcomes were poor. the late 1920s. The first recorded use of this generator was
In England, John Wesley [3], in his famous 1747 treatise Prim- in 1926 at the Brigham Hospital in Boston, where Cushing
itive Physick, described not only the presence of the soul of had a few days earlier failed to remove a tumor form a pa-
man but also that electrical energy was likely to provide a bet- tient’s head because of bleeding. With the aid of Bovie’s
ter outcome for paralytic conditions than any medicine avail- electrosurgical generator, the procedure was completed,
able at the time. The Frenchman Nollet [4] also provided and Bovie and Cushing [11] noted substantially less bleed-
experimentation with early electrical energy in patients with ing during the procedure. It was with use of this original gen-
paralysis; however, his results were less conclusive. erator that the terms ‘‘cut’’ and ‘‘coagulate’’ were coined,
Franklin continued with electrical experimentation with possibly the only negative outcome of the invention inas-
his Dutch colleague, Jan Ingenhousz, who experienced a se- much as these terms have caused considerable problems
ries of electrical shocks to the head that did not kill him but with the understanding of electrosurgery ever since. They re-
only made him highly elated in subsequent days, which led ferred to a continuous and interrupted waveform, respec-
to recommendation of electric shock therapy for persons tively, and we understand that it is the application of
with melancholy [5]. The Italian Luigi Galvani from the energy that causes the effect because it is a continuous wave-
University of Bologna demonstrated the effects of electricity form that is present in bipolar instruments, with their poor
on muscles in a series of experiments on frogs. He showed capacity to divide tissues via vaporization but excellent ca-
that evoked electrical potential caused contraction of pacity to provide hemostasis.
a dead frog’s legs and hypothesized that there was ‘‘animal
electricity’’ as well as ‘‘metallic electricity’’ [6].
Energy Sources Used in Early Operative Laparoscopy:
Not until the 1830s and 1840s did Robert Todd, a contem-
1930 to 1975
porary of Michael Faraday, begin to understand electromag-
netism of the brain and propose how electricity may be used The diagnostic method of visualizing the peritoneal cav-
for medical purposes. Farraday, an English physicist, had ex- ity was introduced in 1911 by Jacobaeus [12], of Stockholm,
Sutton and Abbott. History of Electrosurgery 273

who also termed this new procedure ‘‘laparoscopy.’’ Electro- Fig. 1

surgical energy was not used in laparoscopy until many
Raoul Palmer (1905–1985), the father of laparoscopic surgery. Photo-
years later and could easily have ended in catastrophe, and
graph reproduced with permission of the late Mrs. Elizabeth Palmer.
the surgical revolution provided by laparoscopic surgery
could have died in its infancy.
In 1933, Fervers [13] designed instruments to divide
intraabdominal adhesions using electrosurgery. His account
of this first operation is truly terrifying because he used
oxygen as the distention medium and became increasingly
concerned at the flashes of light and audible explosions pro-
duced by the combination of oxygen and high-frequency
electric current within the abdominal cavity during his first
case [13]. It is nothing short of miraculous that the patient
survived, and it is interesting to reflect that if she had peri-
shed as a result of this extremely dangerous procedure,
laparoscopic surgery would almost certainly have been
banned. Indeed, it was banned in Germany, where the use
of monopolar electrosurgery for tubal occlusion resulted in
many injuries and deaths, resulting in the development of
thermocoagulation that involved the slow heating of tissues
and sealing of vessels and fallopian tubes via protein
denaturation. The following year, Ruddock [14] designed
a single-puncture operating laparoscope that enabled both
biopsy and coagulation, and also used CO2 for insufflation,
a distention medium previously introduced by Zolikofer
[15] in Switzerland and clearly prevented the early catastro-
phes noted with use of flammable gases.
The father of laparoscopic surgery in Europe was Raoul
Palmer (1905–1985) (Fig. 1), who delineated its role in
both infertility and birth control and pioneered laparoscopic
tubal occlusion using electrocoagulation [16]. Palmer, who This technique was further refined by the development in
was head of the gynecological clinic at the Broca Hospital 1977 of special bipolar forceps by Kleppinger [20], and
in Paris, had a leading role in the fight for contraception the instrument still bears his name today.
and termination of pregnancy in France in the 1960s and The pioneering work of Kurt Semm (Fig. 2), a qualified
was often at odds with the medical establishment because engineer and doctor from Kiel, Germany, resulted in many
of his strong views on these subjects. He also was a great of the insufflators and laparoscopic trainers still used today.
teacher of laparoscopic surgery, emphasising the need for Semm was a forceful individual and had to work against
proper training with one of his students, Patrick Steptoe, us- a barrage of criticism from the establishment, which had
ing this technique to retrieve oocytes and leading to the birth banned the use of electrosurgery in Germany because of
of the first baby conceived via in vitro fertilization, Louise its adverse effects and also banned laparoscopy. His solution
Brown, on July 25th 1978. of thermocoagulation [21] and the renaming of the proce-
In 1967, Steptoe [17] wrote the first book on laparoscopy dure as ‘‘pelviscopy’’ enabled Semm and many others in
in the English language, in which he described Palmer’s Germany after him to continue their groundbreaking work.
technique of using monopolar electrosurgery to coagulate With his new energy source, his ‘‘new’’ procedure, and extra-
the tube and divide it. However, this technique caused con- corporeal sutures, Semm performed the first laparoscopic
siderable morbidity including thermal bowel injury, perfora- appendectomy in 1982. Together with his successor, Lise-
tion, and subsequent peritonitis. It was the recognition of the lotte Mettler, he described the technical progress in operative
thermal pathway for a ‘‘monopolar current’’ (a term that is laparoscopy including his approach to total laparoscopic
embedded in history but in reality has no physical basis be- hysterectomy [22].
cause electrosurgery requires completion of a circuit and
therefore is always bipolar) that led to the development of
Operative Laparoscopy 1975 to 1988: Introduction
bipolar coagulation by Rioux and Cloutier [18] in 1974
of Lasers
in North America and Frangenheim [19] in Konstanz,
Germany. The arrangement of the two electrical poles in One of the responses of the medical fraternity to the rec-
close proximity negated the issues of capacitance and stray ognition of the complications associated with electrosurgery
currents causing thermal injury outside the field of view. was to avoid it altogether, and the laser age was born. The
274 Journal of Minimally Invasive Gynecology, Vol 20, No 3, May/June 2013

Fig. 2 via the hysteroscope [29], in which the relatively deep pen-
etration and the ability to function in a fluid medium and seal
Professor Kurt Semm (Kiel, Germany) demonstrating his pelvi-trainer.
vessels was a distinct advantage. However, at laparoscopic
Photograph courtesy of Chris Sutton.
surgery this deep penetration of the bare fiber was hazardous
and led to the introduction of artificial sapphire and quartz
fiber tips to enable laser energy to focus at a point source
and produce a type of laser scalpel while retaining the advan-
tages of flexible fibers and the ability to work in hemorrhagic
areas. Although these devices restored a tactile sense to what
was previously ‘‘no touch’’ surgery, the fibers had a limited
life span or were for single use, which added considerably
to the cost of laparoscopic laser surgery. Experiments have
shown that these devices do not work until they are contam-
inated with tissue debris that ignites, causing the temperature
of the tip to rise to as much as 600 C. In essence, tissue
vaporization is achieved using a hot wire, and a similar
effect could be achieved using an electro-diathermy needle
at a fraction of the cost [30]. To avert this high temperature,
manufacturers produced an optoelectronic control system to
regulate the heating mechanism. A sensor in the laser mea-
sured the temperature of the fiber tip during cutting, and
the laser power was automatically controlled via a servo-
mechanism to keep the temperature at the tip at an effective
safe level below the meltdown threshold [31].
The Nd:YAG laser also had the disadvantage that it was
an invisible laser and at the wavelength of 1064 nm caused
retinal damage if the laser energy entered the eye, and thus
required special protective eyewear. A further refinement
was developed in which the wavelength was halved to 532
nm by optically pumping Nd:YAG energy through a crystal
CO2 laser, probably the most widely used laser in gynecol- of potassium titanyl phosphate, creating a green visible light
ogy, was developed in 1964 by Patel and his colleagues, laser that may be passed down a flexible fiber and is partic-
working at Bell Laboratories in California, for use in the ularly effective in photocoagulation of endometriosis be-
communications industry. This highly specialized instru- cause it has the same absorption peak as hemoglobin and
ment was first adapted for use in laparoscopy by Bruhat hemosiderin. The potassium titanyl phosphate (KTP/532
et al [23] from Clermont-Ferrand in the Auvergne, France. laser), first used in the United States [32], was also useful
They reported this new energy source in the proceedings for treatment of ovarian endometriomas because it works
of an international conference, which was not widely read, well in the presence of blood and has a photoactive effect
and other centers began to experiment with laser laparos- due to its wavelength. The CO2 laser was the first surgical
copy and prototype instruments and techniques developed energy method to be subjected to the rigors of a randomized
independently by Yoni Tadir in Israel [24], James Daniell double-blind trial in the treatment of pelvic pain associated
[24] in the United States, Christopher Sutton [25] in the with endometriosis [33].
United Kingdom, and Jacques Donnez [26] in Belgium. In the early years of laparoscopic surgery, lasers were
Most of these pioneering surgeons were unaware of the widely used as a cutting and coagulation device because
work of others in the field, and although the equipment dif- single-use and self-sharpening scissors were not yet avail-
fered in terms of design and laser delivery, the clinical results able. In addition, at that time, electrosurgery was considered
that they reported were similar. The CO2 laser was remark- unsafe; however, with engineering improvements in the
able for its precision, and in experienced hands was ex- safety of electrosurgery and the development of self-
tremely safe. It had the disadvantage that it could only be limiting safety mechanisms when any form of coupling oc-
used with rigid lens systems and the CO2 was absorbed by curred meant that most lasers were confined to specialized
water and other fluids and was therefore difficult to use in centers, and most laparoscopic surgeons turned to electro-
the presence of a hemorrhagic field. surgery [34].
Use of the Nd:YAG laser for laparoscopic ablation of en- The expense of lasers in both capital cost and ongoing
dometriosis was first described by Lomano [27] and was fur- maintenance was a key factor in its demise from mainstream
ther evaluated by Corson and Grochmal [28]. This laser had minimally invasive surgical practice. The importance of la-
already been used endoscopically for endometrial ablation sers on the path to modern gynecologic minimally invasive
Sutton and Abbott. History of Electrosurgery 275

surgery should not be underestimated, however, because it were satisfactory, but it required substantial technical skill
was the development of laser surgery that averted the early and a powerful, very expensive YAG laser.
and substantial complications of its electrosurgical alterna- In contrast, DeCherney and Polan [39] used an inexpen-
tive. Perhaps of equal value is recognition of the first laparo- sive resectoscope loop, similar to that used by urologists to
scopic cholecystectomy, performed in 1987 by Mouret in resect benign prostatic hyperplasia, to slice the full thickness
Lyon, France, which made equipment suppliers and manu- of the endometrium and control abnormal uterine bleeding
facturers take note of the enormous potential market in lap- due to an endometrial cause. This much less expensive but
aroscopic surgery, and since then there has been substantive still clinically effective step back toward electrosurgery at
development in technology with more effective tissue cut- hysteroscopy enabled the procedure to be performed more
ting, less lateral thermal damage, and large vessel hemosta- widely [39]. The final step in the thermal destruction of
sis using efficient sealing devices. It is the larger market of the endometrium to control abnormal uterine bleeding was
general surgery, not only our own relatively small but impor- made in 1989 by Thierry Vancaillie [40], who used a high-
tant speciality, that has led to electrosurgical equipment be- voltage interrupted current and slowly passed a ball-end
ing delivered on the basis of clinical outcomes, injury electrode over the surface of the endometrium, ensuring
prevention, and economic constraints. more uniform destruction and more consistent results. Roll-
erball ablation is considered the criterion standard in endo-
Development of Energy Sources for Hysteroscopy metrial ablation and is the usual comparator for many
emerging types of endometrial ablation.
The first energy source used for gynecologic surgery was
by Reuben [35], who in 1925 used CO2 as a hysteroscopic New Energy Sources for Laparoscopic Surgery
distention medium and introduced fluid to intermittently
wash away blood that obscured his vision. He wired loops Although energy sources have wavered from electrical
to cause electrosurgical fulguration of a polyp alongside energy to laser and back to electrical energy in both the
the hysteroscope, then used scissors to mechanically dissect uterus and the peritoneal cavities, the principles of electro-
the disease [35]. surgery have remained unchanged because they are physics.
These simple surgeries were followed by more complex Engineering feats to overcome problems are discussed in an-
procedures using electrosurgery and other types of energy other article in this series [41], and the history of electrosur-
to treat abnormal uterine bleeding. Energy sources were gery is now in its current phase, with combination devices
used in attempts to ablate the endometrium as early as that use pressure and electrical energy to create proteina-
1971, when Droegmueller et al [36] used nitrous oxide cryo- ceous seals in vessel walls and other devices that use ultra-
surgery to ablate the endometrium. However, in the follow- sonic rather than electrosurgical energy.
ing year Shenker and Polishuk [37] published a study that
showed that rabbit endometrium regenerated after cryosur- Ultrasonic (harmonic) Scalpel
gery, accounting for the initial poor results. The ultrasonic vibrating scalpel (harmonic scalpel) uses
In 1976, Neuwirth and Amin [38] published an article de- energy to vibrate the tissue cutting blade at 55 500 vibrations
scribing the use of electrosurgery via a urologic resectoscope per second, thereby dividing the intended tissue via genera-
to remove pedunculated submucous myomas either by divid- tion of low heat, which when combined with rapid vibration
ing their pedicles or shaving them off the uterine wall. Fol- causes proteins to denature. This coagulum seals vessels of
lowing this was a swathe of other applications and energy up to 5 mm in diameter and results in minimal bleeding, lat-
sources used within the uterus. Goldrath et al [29] were eral thermal spread, or smoke production. These physical
the first to realize that the Nd:YAG laser would be the ideal properties make it an excellent instrument for use in ad-
laser to photovaporize the endometrium, and reported their vanced laparoscopic procedures such as hysterectomy and
initial results in 1981. Unlike the CO2 laser, the Nd:YAG myomectomy, and it has been popularized by Miller [42],
laser is passed down a flexible fiber, is functional in the who has publicly demonstrated several nearly bloodless
presence of fluid, and has relatively deep penetration, en- myomectomy procedures.
abling it to ablate the endometrium but not the myometrium.
Goldrath demonstrated this limited depth of penetration in
Argon Beam Coagulator
a highly original way by holding a freshly extirpated uterus
in his bare hands while a colleague performed an endome- The argon beam coagulator is often thought to be a laser
trial ablation using the laser. This demonstration suggested but is merely a way of delivering monopolar current to tis-
insufficient heat transmission to cause thermal bowel injury sues. When activated, flow of argon gas removes blood, es-
in vivo, when circulating blood would act as a heat sink. He char, and debris from the target zone, enabling the unipolar
suggested that the procedure would be safe if the fiber itself current to directly affect the bleeding vessel. It is an ex-
did not perforate the uterus. Inasmuch as the procedure was tremely effective device for small vessel hemostasis during
performed under direct vision, this would be unlikely to go vascular procedures such as myomectomy and presacral
unrecognized. Initial clinical results using this technique neurectomy [43]. It does, however, have the disadvantage
276 Journal of Minimally Invasive Gynecology, Vol 20, No 3, May/June 2013

Fig. 3 This simple two-electrode handpiece system involved a rela-

tively high flow of argon gas, with its recognized potential to
Plasma stream from the tip of the PlasmaJet handpiece. Used with
give rise to fatal gas embolism. This hindered subsequent de-
permission from Elsevier Inc.
velopment, and no commercially available system resulted
from this pioneering work. In the mid-1990s, Nikolay Sus-
lov invented a multi-electrode system that generated plasma
with a high power density, using a low level of current and
a low flow of argon gas. Suslov was working on the Russian
space program in Siberia; however, it was realized that this
device had the potential to be an effective tool for laparo-
scopic surgery and resulted in the PlasmaJet system (Plasma
Surgical, Inc., Roswell, GA), which is arguably the only true
plasma surgical device available today because it does not
use an electrosurgical approach and is effective at cutting,
coagulation, and ablation. This device has been evaluated
clinically in the United States by Nezhat et al [45] and in
the United Kingdom by Madhuri et al [46] in the treatment
of endometriosis, and in France by Roman et al [47], who
compared plasma ablation of ovarian endometriomas with
cystectomy and found better preservation of the ovarian pa-
renchyma in the group that received plasma therapy.
that the beam of argon gas can bounce off reflective surfaces
if applied at a low angle of incidence, and there have been
reports of damage to major pelvic vessels because of this. Helium Plasma Devices
Other complications include death from argon embolism The Helica thermal coagulator (Helica Instruments, Ltd.,
because of the high flow of argon gas from the device and Broxburn, Lothian, UK) uses a radiofrequency electrosur-
failure to ensure that the gas was correctly removed before gery source to produce a relatively low-power helium
firing the device. plasma via corona discharge that can be used to fulgurate
or coagulate tissue and is safe and effective for treatment
Plasma Surgery of superficial endometriosis. A similar device, the Bovie
J-Plasma (Bovie Medical Corp., Melville, NY), has been
The latest device to enhance the equipment of the laparo- produced in the United States and has recently received
scopic surgeon uses argon neutral plasma energy, which can approval from the US Food and Drug Administration as a
be delivered down a 5-mm handpiece. The pure thermal coagulation device. It has the added feature of a retractable
plasma flow (Fig. 3) has a substantial advantage in terms electrosurgery blade for cutting.
of safety and minimal damage to adjacent and underlying
tissues. The system is electrically neutral, and because it
Fluid-Coupled Electrosurgery Devices
carries no external electrical current, no ground pad is
necessary and there is no risk of capacitative coupling or Some recently introduced electrosurgical devices that op-
alternate-site burns. erate in a liquid field use the word plasma when describing
The word ‘‘plasma’’ in this sense has nothing to do with the their method of operation; however, in reality they use radio-
bodily fluid but describes ionized gas, the fourth state of mat- frequency electrosurgery via specially designed bipolar
ter after solid, liquid, and gas. When energy is added to a solid, electrode systems to seal vessels. Examples include the Plas-
it melts to form a liquid, and if more heat is added, the liquid maKinetic technology used in the Olympus Plasma Knife
evaporates to form a gas. If further energy is applied, it ionizes (Gyrus ACMI, Southborough, MA) and the ArthroCare co-
and becomes a plasma, which is inherently unstable and gives blation device (ArthoCare Corp., Sunnyvale, CA), which
up its energy in three useful forms for the laparoscopic sur- generates only non-thermal plasma within the tiny bubbles
geon: as light that illuminates the target area, as heat that formed in the fluid on the surface of their electrodes but in
may be used to coagulate a tissue surface and seal small ves- reality relies on basic electrosurgery for its tissue effect. An-
sels, and as kinetic energy that may be used to vaporize tissues other new device, the PEAK PlasmaBlade (PEAK Surgical,
of various densities including the fibrosis associated with Inc., Palo Alto, CA) may generate non-thermal plasma at the
deep infiltrating endometriosis and even bone. interface of the handpiece blade with the tissue or fluid me-
The late John Glover and his colleagues at the University dium in which it is used but, notwithstanding this, it is the
of Indiana associated true thermal plasma with the ability to rapid pulses of high-voltage energy that create the surgical
both cut and coagulate tissue in early studies in the mid- effect. Thus, the generation of non-thermal plasma is merely
1970s in which they first described a plasma scalpel [44]. used to create a conductive pathway for an electric current,
Sutton and Abbott. History of Electrosurgery 277

and the only device that uses the energy of pure plasma is the 7. [Link]
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