- Email: [email protected]
Bipolar electrosurgery: A short history
Journal of Minimally Invasive Gynecology (2007) 14, 538 –541
Bipolar electrosurgery: A short history Jacques-Émile Rioux, MD, MPH From the Department of Obstetrics and Gynecology, Laval University, Quebec, Canada. When Louis Keith asked me to write my recollections of the process by which bipolar electrosurgery came into being, he added, “Be thorough and truthful because, remember, I was there!” He was there indeed, being one of the speakers at a “Postgraduate Course of Diagnostic and Operative Laparoscopy in Gynecology” being given in Quebec, Canada, at le Centre Hospitalier de l’Université Laval for gynecologists of North America and for “The Flying Doctors Teaching Team” of the American Association of Gynecologic Laparoscopists (AAGL) in July 1973. After a day of magisterial teaching in the auditorium of University Hospital (Figure 1) and viewing various exhibitor stands (Figure 2), I proceeded to observe live surgical procedures that were transmitted directly from the operating room to the lecture room for the benefit of attendees who watched on black and white TV monitors. During 1 specific procedure, an electrocoagulation of the tubes for sterilization, an astute observer (Dr. Stephen Corson) asked me to provide him with some information about the unusual forceps I was using at the time. He particularly mentioned the fact that 2 wires were coming to the instrument and that he was unable to see a return electrode. Because the answer to this question was somewhat complicated to explain while I was operating, I told him (and the others that were listening via the 2-way hook-up from the amphitheater to the operating room) that I would bring the device with me to lunch and explain it at that time. Later, in my surgical greens, during lunch (served with wine on a terrace), I arrived with the very first bipolar electrosurgical
The author has no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Jacques-Émile Rioux, MD, MPH, Laval University, 2776 Avenue Sasseville, Québec QC, Canada G1W 1A2. E-mail: [email protected] Submitted May 9, 2007. Accepted for publication June 7, 2007.
1553-4650/$ -see front matter © 2007 AAGL. All rights reserved. doi:10.1016/j.jmig.2007.06.007
forceps in my hands! I proceeded to give the audience the following historical and technical introduction. Early in February 1973, during a staff meeting of the department of gynecology at which our third unrecognized intestinal burn during a laparoscopic sterilization was discussed, we, the combined faculty of the department, came to the conclusion that these were “mysterious” accidents for which we had (at that time) no logical explanation and therefore no way to institute a prevention program. As we were in the process of analyzing our first 1000 laparoscopic sterilizations,1 we came to the realization that the 3 burns were from the same group of gynecologists. This realization led the younger staff and residents to question the ethics of using this dangerous set-up. As you may remember, the only available technique for tubal laparoscopic sterilization was to use unipolar (monopolar) electrosurgical instrumentation. Using a Palmer biopsy forceps connected to a powerful electrical generator, the tube was grasped, and, making sure that the instrument was not touching anything else, the pure coagulating current was applied and burned the tube. The electrical current then had to return to the “ground plate” situated under the patient, therefore via the pelvis, in order to complete the circuit and return to the generator (Figure 3). I left the staff meeting puzzled, but fortunately, I was going skiing for the weekend, at Mont Ste-Anne, the best site in the east of Canada. The skiing was great; and while I was enjoying it, I was thinking about the meeting, the burns, and how to make electricity safer. All of a sudden, it hit me: why not bring the current into 1 prong of the forceps and retrieve it from the other, thus providing the shortest path for the returning current—that is, whatever is between them (Figure 4). My mind was racing and filled with questions. First, can it work? Second, if it does, how come nobody thought about it before? That evening, during a great meal near a fireplace along with much wine, I explained my thoughts to my wife and friends . . . and they did not care! I was devastated. It was as if I’d had the best
Rioux
Bipolar electrosurgery
539
Figure 3 With the unipolar setup, the current is brought to the patient by an instrument and must be retrieved by the ground plate and brought back to the generator. Figure 1 The teachers of the course in July 1973 from left, at the podium. A. Albert Yuzpe (President 1985), Victor Gomel (President 1999), Louis Keith (President 1979), Richard Soderstrom (President 1977), Jordan M. Phillips (President 1971–76), Stephen Corson (President 1982), and Jacques E. Rioux (President 1978).
part of my brain fall out and no one took notice. The following day, Sunday morning, I told my wife to be ready to go home after the morning skiing so that I would have time to go to my workplace in the basement and work on a “safe electrical forceps”! She was unimpressed.
Figure 2 Drs. Phillips and Rioux inspecting a new instrument at one of the stands.
Using sturdy yet malleable wires of coat hangers, I made the prongs, flattening 1 end of each on an anvil and twisting the other ends with pliers to make finger holds. They were insolated by a thin piece of wood introduced in a hollow rigid tubing from 1 of my daughter Sophie’s brooms (Figure 5). I played with it all evening, and the following morning I called the department of electrical engineering of Laval University and made an appointment with 1 of the engineers. I brought my homemade forceps and 1 of my Palmer forceps from the operating room. I explained the whole concept, which the engineer thought was very logical. At least he listened with interest. I left him everything, asking him to make me a bipolar Palmer forceps of the same size and shape. A week later, he called to let me know that he had a prototype instrument ready: it had been sculpted out of a piece of nylon, and he thought it should work (Figure 6). I then took my new device to the hospital, went to see the technicians in electrosurgery, and asked them to make 2 wires fitting my Bovie generator: 1 from “to patient” to 1 prong of my new forceps and 1 from the other prong to the return electrode where the “ground plate” is normally plugged. Last, it was on to the operating room where my
Figure 4 With the bipolar setup, no ground plate is necessary as the current goes from 1 prong to the other in order to complete the circuit.
540
Figure 5 broom!
Journal of Minimally Invasive Gynecology, Vol 14, No 5, September/October 2007
The home version of the bipolar forceps using Sophie’s
nurse did a thorough cleansing and sterilizing. During the course of my next abdominal hysterectomy, I coagulated both tubes: 1 side with my new bipolar instrument and the other with the classical unipolar technique. The pathologist evaluated the depth of coagulation as quite sufficient; the only difference being that on the bipolar side, only the tube was coagulated, whereas on the unipolar side the coagulation had spread into the mesosalpinx. The very first laparoscopic sterilization using my new bipolar forceps was performed on March 12, 1973. The patient was a dear friend, and a mother of 3 children. She was told about the experimental status of the instrument to be used and accepted gladly without having to sign any papers. These were the sweet old days! The bipolar forceps was born! In order to bring it to adulthood, I could have contacted an endoscopic instrument maker or the government agency whose job was to help and advise young inventors: Le Centre de Recherche Industrielle du Québec (CRIQ). I choose the latter, and this was my biggest mistake. I started working with 2 “electrical engineers” who came to the operating room and watched me do cases from the outside and the inside, thanks to the use of a teaching aid (no TV was yet available). Instead of helping me rapidly develop a
Figure 6 forceps.
The very first bipolar forceps: a bipolarized Palmer’s
Figure 7 Evolution of the prototype. (A) The bipolarized Palmer. (B) The first gun (too heavy). (C) The second prototype (too military). (D) The third prototype (better ergonomically).
good working instrument that could be manufactured and sold, they started trying to improve it ergonomically: the handle took the form of a gun on which the contact was placed to eliminate the use of a pedal (Figure 7). Then the electrodes and trocars were made disposable; every new change had to be tried, discarded, ameliorated, etc. So much so that when the course was presented in July, I was still using my original bipolarized Palmer forceps. The government agency did not want me to use it in front of the TV audience because they had not yet received the confirmation that the patents had been granted for Canada, the United States, and 25 countries. But having tried the TV set-up in order to use it during the course, I discovered that when using the unipolar instrument there was too much “snow” on the TV monitors to see clearly; but when using my bipolar, the picture was not perfect but much better for the attendees. Therefore, I insisted on using it. And when questions arose, I said I would bring it with me to lunch, despite the fact that the engineers were very much against the idea. That is why, right after the course, I rushed to have a publication in a medical journal2 in lieu of patents! (They were granted within a month.) Obviously, everybody present at this meeting was very enthusiastic about my invention and encouraged me to proceed as fast as I could to make this new safer instrument available to all. They also suggested that I present it as a scientific exhibit at the forthcoming AAGL meeting to be held in New Orleans. My exhibit was mobbed in spite of the fact that I was next to the one of my friend Kurt Semm. (The tongue waggers attributed this to the presence of my very good-looking wife!) The interest for this new and safer approach to electrosurgery was unbelievable, and we came back with hundreds of addresses of people willing to buy this new forceps as soon as it would become available . . . but it never did because the aforementioned government agency (CRIQ) tried to make the instrument perfect before even having 1 made that could be bettered. They tested it to death. Fortunately, 2 publications were generated with the use of my very first instrument.3,4 Understandably, companies started to produce their own
Rioux
Bipolar electrosurgery
541
versions of the bipolar forceps. Here are a few of them in alphabetic order: ●
●
●
●
Cameron-Miller Company, under the scientific advice of Dr. Stephen Corson,5 came out with an exclusive design: the forceps was bipolar but it was more like a biopsy punch with the capacity to mechanically cut the tube after coagulation. Eder came out with 2: one 5 mm for use in the 2-puncture technique, and one 3 mm for the single-puncture operating laparoscope. Storz, acting under the advice of Dr. George Bercy, produced 1, which is still quite popular. The grasping ends are wider and serrated. Finally, the most popular was made by Wolf under the coaching of Dr. Richard Kleppinger.6 The main feature of this instrument is an extension, beyond the forceps, to coagulate more of the mesosalpinx to allow for greater security when cutting the tubes after coagulation. Also, the company added an ammeter on the generator to indicate when the tube was completely dehydrated. (And I must recognize that “Kleppy” during all his talks gave me credit for the invention of the bipolar principle having had this slide made [Figure 8]).
For some unknown reason, I started doing 3 burns from 1 cm of the cornua and insisted all along that it was not necessary to cut the tube, since this 3-cm burn seemed very adequate in my hands (Figure 9). The mesosalpinx being
Figure 9 The classic “3 burns” technique starting at 1 cm from the cornua as favored by Rioux.
spared, I felt it could be dangerous to cut.7 On the other hand, those using the Kleppinger forceps felt secure in doing so. I was often asked if after coagulating and cutting one should do an hysterosalpingogram to check that the tube was adequately obstructed, and I always was against it believing that it could facilitate reopening the lumen of the tube. I am convinced that the addition of bipolar electrosurgery into the armamentarium of the gynecologist made operative laparoscopy safer and opened the way for more complicated procedures. For example, I was thrilled when Dr. Harry Reich8 used his bipolar forceps to coagulate the uterine arteries and perform the very first laparoscopic hysterectomy, thus opening the way to most major gynecologic surgery being done by the laparoscopic approach.
References
Figure 8 Cartoon made for Dr. Kleppinger who used it to recognize Rioux’s priority as inventor of the bipolar forceps.
1. Rioux JE, Quesnel G, Blanchet J, et al. Laparoscopie: Stérilisation tubaire—étude de 1000 cas et évaluation globale de la méthode. Union Med Canada. 1973;102:1865–1869. 2. Rioux JE, Cloutier D. Stérilisation tubaire par laparoscopie: présentation d’un nouvel instrument bipolaire. Vie Méd Canada Français. 1973; 2:760 –765. 3. Rioux JE, Cloutier D. A new bipolar instrument for laparoscopic tubal sterilization. Am J Obstet Gynecol. 1974;119:737–741. 4. Rioux JE, Cloutier D. Bipolar cautery for sterilization by laparoscopy. J Reprod Med. 1974;13:6 –10. 5. Corson SL. New instruments: laparoscopic bipolar sterilizing forceps— intrauterine manipulator and lavage instrument. Am J Obstet Gynecol. 1976;124:434. 6. Kleppinger RK. Ancillary uses of bipolar forceps. J Reprod Med. 1977;18:254. 7. Yuzpe AA, Rioux JE, Loffer FD, et al. Laparoscopic tubal sterilization by the “burn only” technique. Obstet Gynecol. 1977;49:106 –110. 8. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg. 1989;5:213–219.
Bipolar electrosurgery: A short history Jacques-Émile Rioux, MD, MPH From the Department of Obstetrics and Gynecology, Laval University, Quebec, Canada. When Louis Keith asked me to write my recollections of the process by which bipolar electrosurgery came into being, he added, “Be thorough and truthful because, remember, I was there!” He was there indeed, being one of the speakers at a “Postgraduate Course of Diagnostic and Operative Laparoscopy in Gynecology” being given in Quebec, Canada, at le Centre Hospitalier de l’Université Laval for gynecologists of North America and for “The Flying Doctors Teaching Team” of the American Association of Gynecologic Laparoscopists (AAGL) in July 1973. After a day of magisterial teaching in the auditorium of University Hospital (Figure 1) and viewing various exhibitor stands (Figure 2), I proceeded to observe live surgical procedures that were transmitted directly from the operating room to the lecture room for the benefit of attendees who watched on black and white TV monitors. During 1 specific procedure, an electrocoagulation of the tubes for sterilization, an astute observer (Dr. Stephen Corson) asked me to provide him with some information about the unusual forceps I was using at the time. He particularly mentioned the fact that 2 wires were coming to the instrument and that he was unable to see a return electrode. Because the answer to this question was somewhat complicated to explain while I was operating, I told him (and the others that were listening via the 2-way hook-up from the amphitheater to the operating room) that I would bring the device with me to lunch and explain it at that time. Later, in my surgical greens, during lunch (served with wine on a terrace), I arrived with the very first bipolar electrosurgical
The author has no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Jacques-Émile Rioux, MD, MPH, Laval University, 2776 Avenue Sasseville, Québec QC, Canada G1W 1A2. E-mail: [email protected] Submitted May 9, 2007. Accepted for publication June 7, 2007.
1553-4650/$ -see front matter © 2007 AAGL. All rights reserved. doi:10.1016/j.jmig.2007.06.007
forceps in my hands! I proceeded to give the audience the following historical and technical introduction. Early in February 1973, during a staff meeting of the department of gynecology at which our third unrecognized intestinal burn during a laparoscopic sterilization was discussed, we, the combined faculty of the department, came to the conclusion that these were “mysterious” accidents for which we had (at that time) no logical explanation and therefore no way to institute a prevention program. As we were in the process of analyzing our first 1000 laparoscopic sterilizations,1 we came to the realization that the 3 burns were from the same group of gynecologists. This realization led the younger staff and residents to question the ethics of using this dangerous set-up. As you may remember, the only available technique for tubal laparoscopic sterilization was to use unipolar (monopolar) electrosurgical instrumentation. Using a Palmer biopsy forceps connected to a powerful electrical generator, the tube was grasped, and, making sure that the instrument was not touching anything else, the pure coagulating current was applied and burned the tube. The electrical current then had to return to the “ground plate” situated under the patient, therefore via the pelvis, in order to complete the circuit and return to the generator (Figure 3). I left the staff meeting puzzled, but fortunately, I was going skiing for the weekend, at Mont Ste-Anne, the best site in the east of Canada. The skiing was great; and while I was enjoying it, I was thinking about the meeting, the burns, and how to make electricity safer. All of a sudden, it hit me: why not bring the current into 1 prong of the forceps and retrieve it from the other, thus providing the shortest path for the returning current—that is, whatever is between them (Figure 4). My mind was racing and filled with questions. First, can it work? Second, if it does, how come nobody thought about it before? That evening, during a great meal near a fireplace along with much wine, I explained my thoughts to my wife and friends . . . and they did not care! I was devastated. It was as if I’d had the best
Rioux
Bipolar electrosurgery
539
Figure 3 With the unipolar setup, the current is brought to the patient by an instrument and must be retrieved by the ground plate and brought back to the generator. Figure 1 The teachers of the course in July 1973 from left, at the podium. A. Albert Yuzpe (President 1985), Victor Gomel (President 1999), Louis Keith (President 1979), Richard Soderstrom (President 1977), Jordan M. Phillips (President 1971–76), Stephen Corson (President 1982), and Jacques E. Rioux (President 1978).
part of my brain fall out and no one took notice. The following day, Sunday morning, I told my wife to be ready to go home after the morning skiing so that I would have time to go to my workplace in the basement and work on a “safe electrical forceps”! She was unimpressed.
Figure 2 Drs. Phillips and Rioux inspecting a new instrument at one of the stands.
Using sturdy yet malleable wires of coat hangers, I made the prongs, flattening 1 end of each on an anvil and twisting the other ends with pliers to make finger holds. They were insolated by a thin piece of wood introduced in a hollow rigid tubing from 1 of my daughter Sophie’s brooms (Figure 5). I played with it all evening, and the following morning I called the department of electrical engineering of Laval University and made an appointment with 1 of the engineers. I brought my homemade forceps and 1 of my Palmer forceps from the operating room. I explained the whole concept, which the engineer thought was very logical. At least he listened with interest. I left him everything, asking him to make me a bipolar Palmer forceps of the same size and shape. A week later, he called to let me know that he had a prototype instrument ready: it had been sculpted out of a piece of nylon, and he thought it should work (Figure 6). I then took my new device to the hospital, went to see the technicians in electrosurgery, and asked them to make 2 wires fitting my Bovie generator: 1 from “to patient” to 1 prong of my new forceps and 1 from the other prong to the return electrode where the “ground plate” is normally plugged. Last, it was on to the operating room where my
Figure 4 With the bipolar setup, no ground plate is necessary as the current goes from 1 prong to the other in order to complete the circuit.
540
Figure 5 broom!
Journal of Minimally Invasive Gynecology, Vol 14, No 5, September/October 2007
The home version of the bipolar forceps using Sophie’s
nurse did a thorough cleansing and sterilizing. During the course of my next abdominal hysterectomy, I coagulated both tubes: 1 side with my new bipolar instrument and the other with the classical unipolar technique. The pathologist evaluated the depth of coagulation as quite sufficient; the only difference being that on the bipolar side, only the tube was coagulated, whereas on the unipolar side the coagulation had spread into the mesosalpinx. The very first laparoscopic sterilization using my new bipolar forceps was performed on March 12, 1973. The patient was a dear friend, and a mother of 3 children. She was told about the experimental status of the instrument to be used and accepted gladly without having to sign any papers. These were the sweet old days! The bipolar forceps was born! In order to bring it to adulthood, I could have contacted an endoscopic instrument maker or the government agency whose job was to help and advise young inventors: Le Centre de Recherche Industrielle du Québec (CRIQ). I choose the latter, and this was my biggest mistake. I started working with 2 “electrical engineers” who came to the operating room and watched me do cases from the outside and the inside, thanks to the use of a teaching aid (no TV was yet available). Instead of helping me rapidly develop a
Figure 6 forceps.
The very first bipolar forceps: a bipolarized Palmer’s
Figure 7 Evolution of the prototype. (A) The bipolarized Palmer. (B) The first gun (too heavy). (C) The second prototype (too military). (D) The third prototype (better ergonomically).
good working instrument that could be manufactured and sold, they started trying to improve it ergonomically: the handle took the form of a gun on which the contact was placed to eliminate the use of a pedal (Figure 7). Then the electrodes and trocars were made disposable; every new change had to be tried, discarded, ameliorated, etc. So much so that when the course was presented in July, I was still using my original bipolarized Palmer forceps. The government agency did not want me to use it in front of the TV audience because they had not yet received the confirmation that the patents had been granted for Canada, the United States, and 25 countries. But having tried the TV set-up in order to use it during the course, I discovered that when using the unipolar instrument there was too much “snow” on the TV monitors to see clearly; but when using my bipolar, the picture was not perfect but much better for the attendees. Therefore, I insisted on using it. And when questions arose, I said I would bring it with me to lunch, despite the fact that the engineers were very much against the idea. That is why, right after the course, I rushed to have a publication in a medical journal2 in lieu of patents! (They were granted within a month.) Obviously, everybody present at this meeting was very enthusiastic about my invention and encouraged me to proceed as fast as I could to make this new safer instrument available to all. They also suggested that I present it as a scientific exhibit at the forthcoming AAGL meeting to be held in New Orleans. My exhibit was mobbed in spite of the fact that I was next to the one of my friend Kurt Semm. (The tongue waggers attributed this to the presence of my very good-looking wife!) The interest for this new and safer approach to electrosurgery was unbelievable, and we came back with hundreds of addresses of people willing to buy this new forceps as soon as it would become available . . . but it never did because the aforementioned government agency (CRIQ) tried to make the instrument perfect before even having 1 made that could be bettered. They tested it to death. Fortunately, 2 publications were generated with the use of my very first instrument.3,4 Understandably, companies started to produce their own
Rioux
Bipolar electrosurgery
541
versions of the bipolar forceps. Here are a few of them in alphabetic order: ●
●
●
●
Cameron-Miller Company, under the scientific advice of Dr. Stephen Corson,5 came out with an exclusive design: the forceps was bipolar but it was more like a biopsy punch with the capacity to mechanically cut the tube after coagulation. Eder came out with 2: one 5 mm for use in the 2-puncture technique, and one 3 mm for the single-puncture operating laparoscope. Storz, acting under the advice of Dr. George Bercy, produced 1, which is still quite popular. The grasping ends are wider and serrated. Finally, the most popular was made by Wolf under the coaching of Dr. Richard Kleppinger.6 The main feature of this instrument is an extension, beyond the forceps, to coagulate more of the mesosalpinx to allow for greater security when cutting the tubes after coagulation. Also, the company added an ammeter on the generator to indicate when the tube was completely dehydrated. (And I must recognize that “Kleppy” during all his talks gave me credit for the invention of the bipolar principle having had this slide made [Figure 8]).
For some unknown reason, I started doing 3 burns from 1 cm of the cornua and insisted all along that it was not necessary to cut the tube, since this 3-cm burn seemed very adequate in my hands (Figure 9). The mesosalpinx being
Figure 9 The classic “3 burns” technique starting at 1 cm from the cornua as favored by Rioux.
spared, I felt it could be dangerous to cut.7 On the other hand, those using the Kleppinger forceps felt secure in doing so. I was often asked if after coagulating and cutting one should do an hysterosalpingogram to check that the tube was adequately obstructed, and I always was against it believing that it could facilitate reopening the lumen of the tube. I am convinced that the addition of bipolar electrosurgery into the armamentarium of the gynecologist made operative laparoscopy safer and opened the way for more complicated procedures. For example, I was thrilled when Dr. Harry Reich8 used his bipolar forceps to coagulate the uterine arteries and perform the very first laparoscopic hysterectomy, thus opening the way to most major gynecologic surgery being done by the laparoscopic approach.
References
Figure 8 Cartoon made for Dr. Kleppinger who used it to recognize Rioux’s priority as inventor of the bipolar forceps.
1. Rioux JE, Quesnel G, Blanchet J, et al. Laparoscopie: Stérilisation tubaire—étude de 1000 cas et évaluation globale de la méthode. Union Med Canada. 1973;102:1865–1869. 2. Rioux JE, Cloutier D. Stérilisation tubaire par laparoscopie: présentation d’un nouvel instrument bipolaire. Vie Méd Canada Français. 1973; 2:760 –765. 3. Rioux JE, Cloutier D. A new bipolar instrument for laparoscopic tubal sterilization. Am J Obstet Gynecol. 1974;119:737–741. 4. Rioux JE, Cloutier D. Bipolar cautery for sterilization by laparoscopy. J Reprod Med. 1974;13:6 –10. 5. Corson SL. New instruments: laparoscopic bipolar sterilizing forceps— intrauterine manipulator and lavage instrument. Am J Obstet Gynecol. 1976;124:434. 6. Kleppinger RK. Ancillary uses of bipolar forceps. J Reprod Med. 1977;18:254. 7. Yuzpe AA, Rioux JE, Loffer FD, et al. Laparoscopic tubal sterilization by the “burn only” technique. Obstet Gynecol. 1977;49:106 –110. 8. Reich H, Decaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg. 1989;5:213–219.