Coblation in ent

HISTORICAL PERSPECTIVE
• The technology of using plasma to ablate biological tissue was first described by Woloszko
and Gilbride .
• Radio frequency technology for medical use (for cutting, coagulation and tissue dessication)
was popularized by Cushing and Bovie .
• Cushing an eminent neurosurgeon found this technology excellent for his neurosurgical
procedures. First use of this technology inside the operating room took place on october 1st
1926 at Peter Bent Brigham Hospital in Boston, Massachusetts. It was Dr Cushing who
removed a troublesome intracranial tumor using this equipment.

COBLATION
• The term coblation is derived from “Controlled ablation”.
• The Coblation process was invented by Philip E. Eggers and Hira V. Thapliyal, who
patented their “electrosurgical ablation probe” on May 11, 1999. The technology was
acquired by ArthroCare (founded in 1993), a California-based medical device company,
which trademarked the technology under the term Coblationâ€”a contraction of “controlled”
and “ablation”.
• This was actually a fortuitous discovery in their quest for unblocking coronary arteries
using electrosurgical energy.
• Initially coblation technology was used in arthroscopic surgeries immensely benefiting
injured athletes.

PLASMA MEDICINE
Medical effects of plasma has spurred a evolution of new science “Plasma Medicine”. It is now
evidently clear that Plasma not only has physical effects (cutting and coagulation) on the
tissues but also other beneficial therapeutic effects too. Plasma not only coagulates blood
vessels but also decontaminates surgical wound thereby facilitating better wound healing.
Therapeutic application of plasma assumes that plasma discharges are ignited at atmospheric
pressure.
1. Plasma assisted modification of biorelevant surfaces
2. Plasma based decontamination and sterilization
3. Direct therapeutic application

PLASMA ASSISTED MODIFICATION OF
BIORELEVANT SURFACES
• This technique is used to optimize the biofunctionality of implants, or to qualify polymer
surfaces for cell culturing and tissue engineering.
• For this purpose gases that do not fragment into polymerisable intermediaries upon
excitation should be used.
• Gases that do not fragment include air, nitrogen, argon, oxygen, nitrous oxide and helium.
• Exposure to such plasma leads to new chemical functionalities.

PLASMA BASED DECONTAMINATION AND
STERILIZATION
• Not all surgical instruments can be effectively sterilized using currently available
technologies. This is due to the fact that plastics cannot be effectively be sterilized by
conventional means as it could get degraded on exposure to steam and heat. Plasma
discharges have been found to be really useful in this scenario because of its low temperature
action.
• The nature of plasma actions on bacteria extends from sublethan to lethal effects. Sublethal
effects cause bacteriostatic changes, while lethal effects cause bacteriocidal changes.
• Growth of drug resistant bacteria MRSA in hospital environment poses a great challenge in
sterilization efforts. Ideal sterilization mechanism should be fast and efficient. Studies
reveal that plasma devices perform this action rather effortlessly .

DIRECT THERAPEUTIC APPLICATIONS
• Antifungal therapy: Plasmas can be employed to treat fungal infections. Common fungal
ailments like T pedis can be managed using plasma technology .
• Dental care: Periodontal infections are common in older age group patients and pregnant
mothers. Plasmas have an ability to penetrate microscopic openings between teeth and gum
destroying the offending organism .
• Management of chronic wound: Eventhough plasma does not play direct role in wound
healing, its bactericidal and fungicidal effects helps in wound healing .
• Surgeries: Currently plasma technology is being used to perform blood less surgeries like
tonsillectomy etc.

PRINCIPLE OF COBLATION
• K.R. Stalder and J. Woloszko did pioneering work in formation of microplasma produced by
electrical discharges in saline environment. This microplasma caused surgical ablation of
tissues and improved surgical outcomes.
• Wand is the electrode (disposable) used in coblation as a knife to cause ablation.
coblator wand with three
electrodes separated by
ceramic

• Coblation is non-thermal volumetric tissue removal through molecular dissociation.
• Coblation methods use radiofrequency (RF) to remove tissue. RF is a form of energy like radio
waves, but with a higher frequency. Coblation-based surgical procedures use RF energy in a
precise and controlled manner to remove affected tissue while causing very little harm to
healthy tissue.
• This technology uses the principle that when electric current is passed through a conducting
fluid, a charged layer of particles known as the plasma is released.
• These charged particles has a tendency to accelerate through plasma, and gains energy to
break the molecular bonds within the cells. This ultimately causes disintegration of cells
molecule by molecule causing volumetric reduction of tissue.

• Using radio frequency in a bipolar mode with a conductive solution, such as saline,
Coblation energizes the ions in the saline to form a small plasma field. The plasma
has enough energy to break the tissue’s molecular bonds, creating an ablative path.
The thermal effect of this process is approximately 40-70 Â°C, significantly lower
than traditional radio-frequency techniques

• Coblation technology is based on non heat driven process of soft tissue dissolution which
makes use of bipolar radio frequency energy . This energy is made to flow through a
conductive medium like normal saline.
• When current from radiofrequency probe passes through saline medium it breaks saline into
sodium and chloride ions. These highly energized ions form a plasma field strong enough to
break organic molecular bonds within soft tissue causing its dissolution.
• Since 1950’s high frequency electrosurgical apparatus have been in use. In conventional high
frequency apparatus heat is made use of to cause tissue ablation and coagulation. The heat
generated happens to be a double edged weapon causing collateral damage to normal tissues.
• Coblation is acutally a benefical offshoot of high frequency radio frequency energy. The
excellent conductivity of saline is made use of in this technology. This conductivity is
responsible for high energy plasma generation.

STAGES OF PLASMA GENERATION
• First stage – (Vapour gas piston formation):
This is characterised by transition from bubble to film boiling. This decreases heat
emission and causes increase in surface temperature.
• Second stage – Stage of vapour film pulsation:
Tissue ablation occurs during this stage.
• Third stage – Reduction of amplitude of current across the electrodes.
• Fourth stage - Dissipation of electron energy at the metal electrod surface
• Fifth stage (stage of thermal dissipation of energy): This stage is essentially due to
recombination of plasma ions, active atoms and molecules.
These stages explain why coblation is effective if applied intermittently. This ensures
constant presence of stage of vapour film pulsation which is important for tissue ablation.

EFFECT OF PLASMA ON TISSUE
• The effect of plasma on tissue is purely chemical and not thermal. Plasma generates
H and OH ions. It is these ions that make plasma destructive. OH radical causes
protein degradation.
• When coblation is being used to perform surgery the interface between plasma and
dissected tissue acts as a gate for charged particles.
• In nutshell coblation causes low temperature molecular disintegration. This causes
volumetric removal of tissue with minimal damage to adjacent tissue . (Collateral
damage is low).

ELECTROCAUTERY MONOPOLAR
DIATHERMY
BIPOLAR DIATHERMY COBLATOR
This involves direct
current.
Electrons flow only in
one direction and they
dont enter the patient’s
body.
High tissue
temperatures are
reached causing lots of
collateral damage.
Active electrode is
located in the surgical
equipment.
Return electrode is the
diathermy earth pad
placed on the patient.
The generator directs
current from the active
electrode, through the
patient’s body, to the
grounding electrode and
then back to the
generator.
Good for heavy bleeders.
Conventional bipolar
cautery - current is
delivered through a
forceps like device.
One prong serves as
active electrode, while
the other serves as
return electrode.
Current flows from one
prong through the tissue
to the other prong.
Active and return
electrodes are housed in
the same shaft.
Operates at low
temperature and
frequency. Current has
to
travel only through a
shorter path and does
not travel through
the patient.

COMPONENTS OF COBLATION SYSTEM
1. RF generator
2. Foot pedal control
3. Irrigation system
4. Wand

RF GENERATOR
• This generator generates RF signals. It is controlled by microprocessor.
• This generator is capable of adjusting the settings as per the type of wand inserted.
• It automatically senses the type of the wand and adjusts settings accordingly.
Manual override of the preset settings is also possible.
• Two settings are set i.e. coblation and cauterization.
For a tonsil wand the recommended settings would be :
Coblation – 7 (plasma setting)
Cauterization – 3 (Non plasma setting)

FOOT PEDALS
• It has two color coded pedals.
• Yellow one is for coblation and the blue one is for RF cautery.
• This device also emits different sounds when these pedals are pressed indicating to
the surgeon which mode is getting activated

PICS
• Tonsil and adenoid wand
• Laryngeal wand – normal / mini
• Nasal wand
• Seperate tunelling wands are available for tongue base reduction

Laryngeal wand
Figure showing
MLW wand

EQUIPMENT SPECIFICATION
1. Modes of operation – Dissection, ablation, and coagulation
2. Operating frequency – 100 khz
3. Power consumption – 110/240 v, 50/60 Khz
The thickenss of plasma is only 100-200 μm thick around the active electrode.

• Coblation wand has two electrodes i.e. Base electrode and active electrode. These
electrodes are separated by ceramic.
• Saline flows between these two electrodes.
• Current generated flows between these two electodes via the saline medium.
• Saline gets broken down into ions thereby forming active plasma which ablates
tissue.

• Efficiency of ablation can be improved by:
1. Intermittent application of ablation mode
2. Copious irrigation of normal saline
3. By using cold saline plasma generated becomes more efficient in ablating tissue.
Cold saline can be prepared by placing the saline pack in a refrigerator over night.

• Coblation is a smokeless procedure.
• If smoke is seen to be generated during the procedure it indicates the presence of
ablated tissue in the wand between the electrodes.
• Hence a smoking wand should be flushed using a syringe to remove soft tissue ablated
particles between the electrodes.
• The generated frequency from coblator should atleast be 200 kHz since frequencies
lower than 100 kHz can cause neuromuscular excitation when the wand accidentally
comes into contact with neuromuscular tissue.

MODES
• Coblator has been designed to operate in two different modes:
• Ablation mode: As the RF controller setting is increased from 1 to 9 in the coblation
mode, the performance of the wand transitions from thermal effect to ablative effect due
to creation and increase in the intensity of plasma. When the controller setting in the
coblation mode increases the plasma field increases in size and the thermal effect
decreases accordingly.
• Coagulation mode: All coblation wands have been designed to operate in coagulation
mode for hemostasis during surgery. Since the wand is bipolar in nature, it sends energy
through the desired tissue area, through resistive heating process.

USES IN ENT
• Adenotonsillectomy
• Tongue base reduction
• Tongue channeling
• Uvulo palato pharyngoplasty
• Cordectomy
• Removal of benign lesions of larynx including papilloma
• Kashima’s procedure for bilateral abductor paralysis
• Turbinate reduction
• Nasal polypectomy

TONSILLECTOMY
• This process was invented by Philip E Eggers and Hira V Thapliyal in 1999. Coblation
tonsillectomy received FDA approval in 2001.
• Advantages of coblation tonsillectomy:
1. Less bleeding
2. Preservation of capsule is possible if done under magnification. If capsule is preserved
there is less post operative pain
3. Tonsillar reduction surgeries can be performed in young children without compromising
the immunological function of the lymphoid tissue

• Disadvantages of coblation:
1. Cost of wand is high.
2. It can be used only once because secondary infections / secondary bleeding following
coblation surgery using already used wand is high.
3. Reuse of wands should be discouraged because plasma generation is not optimal
when wands are reused.
4.Post operative secondary bleeding is common in coblation tonsillectomy when
compared with that of conventional cold steel method.

ADENOIDECTOMY
• Coblation adenoidectomy is currently becoming popular because:
1. It facilitates complete removal of adenoid tissue under direct vision
2. Bleeding is very minimal
3. Every area of the nasopharynx is accessible to the wand tip
4. Lower incidence of left over residual adenoid tissue
5. Lower risk of complications

• Disadvantages of coblation adenoidectomy:
• 1. Cost involved is high
• 2. Operating time is more when compared to conventional adenoidectomy
• 3. Author encountered significant secondary bleeding following coblation
adenoidectomy in one patient. Post nasal pack and hospitalization was needed
before the patient recovered.

COBLATION KASHIMA PROCEDURE
(POSTERIOR CORDOTOMY)
• Posterior cordotomy (Dennis Kashima procedure) using coblation techonology is
really promising therapy for patients with bilateral abductor paralysis. This
procedure restores sufficient glottic space without causing damage to phonatory and
sphincteric functions of larynx.
• Advantages of this procedure include:
• 1. Bloodless ablation
• 2. Precise ablation of tissue
• 3. No collateral damage to adjacent tissue
• 4. No oedema to tissues around larynx
• 5. Early decannulation is possible

site of resection in
kashima’s procedure
Recker’s modification of
Kashima’s procedure

various stages of
Kashima’s
procedure

MICOLARYNGEAL SURGICAL PROCEDURES
• Advantages of coblation in microlaryngeal surgeries:
1. Damage to adjacent normal tissue is minimal or negligible
2. Mucosal surface of vocal folds heal rather quickly as evidenced by the return of normal
mucosal wave pattern within 6 weeks following surgery
3. There is absolutely zero risk of airway fire
4. There is absolutely negligible bleeding during surgery
5. Healing is rapid because formation of exudate is rather minimal
6. Even bilateral vocal fold lesions can be addressed in the same sitting because the risk of
web formation is rather minimal because of reduced exudate formation
7. Anterior commissure lesions can be addressed without fear of blunting

CORDECTOMY
• Advantages of coblation endoscopic cordectomy include:
• 1. Easy and simple to perform
• 2. Less expensive
• 3. Preserves voice and other protective functions of larynx

LINGUAL TONSILLECTOMY
Evac 70 tonsil wand is seen
ablating lingual tonsil
Picture showing the end result of lingual
tonsil ablation. Note the lingual
musculature after removal of lymphoid
tissue

• Advantages of coblation technology in removal of lingal tonsil are:
• 1. Bloodless field
• 2. Complete ablation is possible
• 3. Less post op oedema
• 4. Post op pain lesser than that of other procedures

OSA
• Potential sites of obstruction in obstructive sleep apnoea include:
1. Nose
2. Palate
3. Tongue base
4. Lateral pharyngeal wall collapse
• Coblation as a tool can easily address tonsil, palate, and tongue. Hence it is an
excellent tool in the surgical management of obstructive sleep apnoea.

UVULOPALATOPHARYNGOPLASTY
elevation of triangular mucosal flap
on either side of Uvula
Tonsillectomy being performed with
preservation of pillar mucosa

Para Uvular wedge created is
sutured with that of anterior
pillar of tonsil everting the soft
palate
Uvular stump eversion stitch
being applied. This stitch
opens up the nasopharynx

End result after surgeryImage showing pillar
suturing being performed

OTHERS
• Malignant tumor of oropharynx - Can it be ablated ?
• Advantages of coblation technology in managing oropharyngeal malignant tumors
include:
• 1. Relatively bloodless field
• 2. Mucosal healing is better because of less collateral damage to adjacent normal tissue
• 3. Since this surgery is being performed under microscopy tumor margins can be
adequate
• 4. Eventhough it is a blunt instrument, author did not face any difficulty with the
plasma wand as far as precision is concerned.
• 5. The wand can also be bent to suit oropharyngeal anatomy

RHINOPHYMA EXCISION ROLE OF
COBLATION

MANAGEMENT OF OROPHARYNGEAL
HEMANGIOMA
hemangioma involving posterior
third of tongue

REFERENCES
• J. Woloszko et al., Lasers in Surgery: Advanced Characterization, Therapeutics, and Systems X,
R. R. Anderson et al., Eds. Bellingham, WA: SPIE, 2000, vol. 3907, pp. 306–316
• H. Cushing and W. T. Bovie, “Electrosurgery as an aid to the removal of intracranial tumors,”
Surg. Gynecol. Obstet., vol. 47, pp. 751–784, 1928.
• M. Laroussi and X. Lu, “Room-temperature atmospheric pressure plasma plume for biomedical
applications,” Applied Physics Letters 87 (11) (2005).
• Ulrich Kogelschatz, “Dielectric-Barrier Discharges: Their History, Discharge Physics, and
Industrial Applications,” Plasma Chemistry and Plasma Processing 23 (1), 1-46 (2003)
• B. Qi, Ren C., Wang D., Li SZ., Wang K., and Zhang Y., “Uniform glowlike plasma source
assisted by preionization of spark in ambient air at atmospheric pressure,” Applied Physics
Letters 89, 131503 (2006).
• Grundmann H, Aires-de-Sousa M, Boyce J and Tiemersma E 2006 Emergence and resurgence of
meticillinresistant Staphylococcus aureus as a public-health threat Lancet 368 874–85

• Morfill G et al 2009 Nosocomical infections—a new approach towards preventive medicine
using plasmas New J. Phys. 11 115019
• Klein L and Gibbs R 2004 Use if microbial cultures and antibiotics in the prevention of
infection-associated preterm birth AJOG 190 1493–502
• Etufugh C N and Phillips T J 2007 Venous ulcers Clin. Dermatol. 25 121–30
• S.V Belov, Use of High-Frequency Cold Plasma Ablation Technology for Electrosurgery
with Minimized Invasiveness,Biomedical Engineering,Vol38,no2,2004,pp80-85.
• V.N Sergeev, S.V.Belov Coblation Technology:a New Method for High Frequency
Electrosurgery,Biomedical Engineering,Vol37,No 1,2003,pp22-25

• Using radio frequency in a bipolar mode with a conductive solution, such as saline,
Coblation energizes the ions in the saline to form a small plasma field. The plasma has
enough energy to break the tissue’s molecular bonds, creating an ablative path. The
thermal effect of this process is approximately 40-70 Â°C, significantly lower than
traditional radio-frequency techniques
• The Coblation process was invented by Philip E. Eggers and Hira V. Thapliyal, who
patented their “electrosurgical ablation probe” on May 11, 1999. The technology was
acquired by ArthroCare (founded in 1993), a California-based medical device company,
which trademarked the technology under the term Coblationâ€”a contraction of
“controlled” and “ablation”. The Coblation procedure is performed using specially
designed hand pieces called Coblation wands.

• Advantages
• and Significantly less pain and less frequent use of narcotics
• and Significantly faster return to normal diet
• and Less incidence of postoperative nausea and throat swelling
• and Less depth of thermal adjacent tissue necrosis
• and Less postoperative dehydration

Coblation in ent

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