MUCOSAL RESECTION (EMR) WITH ENDO CUT Q. - Elmed

ELECTROSURGERYENDO CUTENDOSCOPIC POLYPECTOMY ANDMUCOSAL RESECTION (EMR) WITH ENDO CUT Q.Perfection for Life

CONTENTSIntroduction 31 Technology 4ENDO CUT Q 4Cutting cycle 4Coagulation cycle 5Equipment 5User interface 5Experts mode 5Activation and activation signals 52 In Practice 6General parameter settings 6Operative techniques 7Preparation for polypectomy proceduresand mucosal resection 7Polypectomy procedures at theupper margins 9Endoscopic Mucosal Resection (EMR)at the upper margins 103 Avoiding Complications 12Literature 14Recommended SettingsInsertImportant noteThe authors and ERBE Elektromedizin GmbH have taken thegreatest possible care when compiling these recommendations.Nevertheless, it is impossible to exclude the possibility that errorsmay be contained herein. The information and recommendationsgiven here may not be construed as constituting any basis for anyclaims against the authors or against ERBE Elektromedizin GmbHor against the physicians in the clinical centers on whose clinicalexperience the suggested settings are also based. Should legalregulations stipulate liability, such liability shall be limited tointentional misconduct or gross negligence. The data respectingrecommended settings, areas of application, application durationor the use of instruments is based on clinical experience, althoughit is important to remember that individual centers and physiciansmay favor settings which differ from the recommended settingsgiven here. All values are merely guidelines, the applicabilityof which must be verified by the operator. Depending on thecircumstances it may be necessary to deviate from the values andsettings given in this brochure.Medical science is subject to a process of permanent change basedon research and clinical experience. It may therefore also beappropriate to deviate from the values and settings given in thisbrochure on the basis of the results of such research and experience.2

INTRODUCTIONWith the development of new endoscopic resection andhemostasis techniques, the removal of large polyps orother suspicious mucosal lesions is now possible withoutthe need for open surgery.In endoscopic polypectomy and mucosectomy procedures,ERBE ENDO CUT has established itself as an acceptedmodality.The ENDO CUT Q of the ERBE VIO system is a furtherdevelopment of the ENDO CUT offered by the “ERBOTOMICC” 200 and 350 Model units which have been successfullyused for more than 10 years. This brochure is intendedto help users understand the ENDO CUT Q and to use itcorrectly in their general clinical practice. The brochuretargets both endoscopists and the entire endoscopy team.Contact AddressesERBE Elektromedizin GmbHWaldhörnlestrasse 17D-72072 Tübingen, GermanyPhone +49 70 71/7 55-0Fax +49 70 71/7 55-179ERBE Customer HotlinePhone +49 70 71/7 55-123Fax +49 70 71/7 55-51 23E-Mail: support@erbe-med.deERBE Technical ServicesPhone +49 70 71/7 55-437Fax +49 70 71/7 55-189E-Mail: techservice@erbe-med.deThis brochure was created in close cooperation with experiencedendoscopists working at different medical centers.Our particular thanks go to Prof. Schmitt in Neuperlach-Munich and Prof. Schulz in Berlin.3

1 TECHNOLOGYENDO CUT QThe fractionated cutting mode ENDO CUT Q is characterizedby alternating cutting and coagulation cycles (Fig. 1).This makes it possible to carry out controlled cutting withsimultaneous hemostasis during the entire cuttingprocess, supporting the work of the operating physician.In the more than 10 years in which ENDO CUT has beenused in endoscopic procedures, experience has shown thatvoltage regulation and arcing recognition are the centralfeatures determining the quality and reproducibility ofthe cuts.ENDO CUT Q is a further development which enables largerlesions, particularly polyps, to be resected.ENDO CUT Q is a monopolar high-frequency electrosurgicaltechnique which is based on a two-stage cutting cyclefollowed by a coagulation cycle (Fig. 2):Cutting cyclea) initial incision phaseb) cutting phaseCoagulation cycleUvoltage1. Cutting cyclea) Initial incision phaseA cutting cycle will always begin with a short initial incisionstage of varying duration (Fig. 2). This serves to heatthe tissue in the immediate vicinity of the electrosurgicalsnare endogenously within a few tenths of a second to> 100°C, leading to an initial coagulation (hemostasis) ofthe tissue prior to the actual cutting.The duration of the initial cutting stage is mainly dependenton the diameter of the snare wire, diameter of thepolyp, and the traction of the snare on the tissue it hasgrasped.However, the initial cutting stage should be as short aspossible to prevent deep coagulation at the base of thepolyp. The quicker the cutting phase is arrived at, themore superficial the coagulated area will be.In the following illustrations the cutting cycle is simplydepicted as a yellow bar.b) Cutting phaseThe beginning of the cutting phase is characterized by thedevelopment of electric arcs (sparks) between the tissueand the electrosurgical snare (Fig. 3). The arcs are generatedwith a voltage > 200 volts as soon as the vaporizationof liquid in the tissue creates a small gap between theelectrosurgical snare and the grasped tissue.coagulation cyclecutting cyclettimeTo create controlled and reproducible cuts the formationof sparks must be automatically detected. This will ensurethat the length of the cut is reproducible.With the cutting mode ENDO CUT Q the cutting stage istherefore automatically regulated using recognition ofspark formation.Fig. 1: Intermittent cutting modeENDO CUT Q: cutting cycle yellow, coagulation cycle blue.Uvoltagecoagulationcyclecutting stageinitial incision stagecutting cyclettimecutting intervalFig. 2: Cutting cycle with ENDO CUT Q: initial incision phase(yellow/blue), cutting phase (yellow) and coagulation cycle (blue).Fig 3: When cutting with asnare, small arcs (yellow) arecreated between the snare andthe grasped tissue. The coagulationarea in this illustration isgray/white. Arrow: direction oftraction created by the snare.4

TECHNOLOGY2. Coagulation cycleDuring the coagulation cycle the tissue is prepared for thenext cutting cycle to ensure proper hemostasis prior to thesubsequent cut.The intensity of the coagulation, the so-called coagulationeffect, can be modified with ENDO CUT Q with the help offour different settings.The duration of the coagulation cycle can be finely adjustedusing the Expert mode (cf. the chapter “Cutting interval”on page 8). It is important to remember that coagulationis significantly influenced by the effect setting andless by the duration of the coagulation process.Depending on the chosen setting the coagulated area willincrease towards the base of the polyp in the direction ofthe current flow (Fig. 4).IIIIFig. 4: Coagulation duringcutting. The coagulated area(gray/white) is increased towardsthe base of the polyp. Arrows:Direction of current flow.User interfaceENDO CUT Q is a cutting mode. This means that on themonitor or the user interface the ENDO CUT Q is displayedin the yellow field (Fig. 6).Normally only the parameter “Effect” is displayed whichallows the intensity of the coagulation to be adjustedduring cutting.Expert modeIt is possible to activate the Expert mode to carry out individualadjustments (Fig. 7). If the Expert mode is activated(which should only be carried out by a trained ERBE representative)the parameters “Cutting duration” and“Cutting interval” will also be displayed on the interfaceand can also be adjusted.Activation and activation signalsENDO CUT Q is activated by pressing the yellow footpedal. The user is made aware of the activation by anacoustic signal, the activation signal.As soon as cutting effectively begins, a second acoustic signalwill be heard, the cutting signal. The cutting signal servesas an acoustic control for the actual cutting.The yellow pedal of the foot switch should be presseddown until the polyp or the tissue grasped by the snarehas been completely severed.The cutting stage can be interrupted at any time by ceasingto activate the foot pedal.EQUIPMENTENDO CUT Q is a consequential further development ofENDO CUT, a well-known feature of the ICC units.The Endo Cut Q mode, an optional upgrade, is availablefor the electrosurgical VIO units, some of which can alsobe equipped with it retroactively.A complete system for endoscopicprocedures can consist of the following(Fig. 5):Electro Surgical Unit (ESU)[Model VIO 300 D]Argon Plasma Coagulator(APC) (Model APC 2)Endoscopy Irrigation Pump(Model EIP 2)Integrated on the VIO CartFig. 6: User interface of the VIO systemModeENDO CUT QEffect3Fig. 5: GI work station VIO 300 D.Cut-max. Watt Cutintervalduration18016Fig 7: ENDO CUT Qin the Expert mode.5

2 IN PRACTICEGENERAL PARAMETER SETTINGSEffect settingsDepending on the size, the shape and the location of thepolyp it will be necessary to use different coagulationeffects to ensure that the polypectomy is carried out withas little loss of blood as possible and with the lowest possiblerisk of perforation.The intensity of the coagulation can be adjusted with thehelp of the parameter “Effect” using four different Effectsettings.Setting 1With Setting 1 no coagulation is carried out between theindividual cutting cycles (Fig. 8). This is a purely cuttingcurrent.UvoltageUvoltageCutting durationeffect setting 2–4ttimeFig. 9: The coagulation effect (blue) can be increased with ENDO CUT Qusing the Effect Settings 2– 4.Depending on the size, shape and location of polyps orother lesions it may be beneficial to vary the duration ofcutting.The extent of the cut is significantly dependent on theduration of cutting and can be adjusted using 4 differentsettings (only in the Expert mode, cf. page 6 for furtherdetails) (Fig. 10).Setting 1 is suitable for the resection of polyps in high-riskareas where the walls are particularly thin, because ifthermal damage occurs here due to too intense coagulationthere is a risk of perforation.Setting 2With Setting 2 a very slight coagulation is carried out betweenthe individual cutting cycles (Fig. 9).Setting 3effect setting 1ttimeFig. 8: ENDO CUT Q with Setting 1: cutting current (yellow) withoutcoagulation.Setting 1:setting 1 setting 4cut duration setting 1 cut duration setting 4Fig. 10: The cutting duration can be individually adjusted withENDO CUT Q: left side = Setting 1, limited cut; right side = Setting 4,extensive cut.With Setting 1 the cutting duration is very brief, whichalso limits the extent of the cut (Fig. 11). Due to the verysmall cuts resection is very slow.UvoltageWith Setting 3 the coagulation between the individualcutting cycles is increased (Fig. 9).Setting 4With Setting 4 the coagulation between the individualcutting cycles is maximized. This setting is particularly suitablefor applications which require extensive coagulation(Fig. 9).cutting cyclecut duration setting 1ttimeFig. 11: ENDO CUT Q with a very short cutting duration: Setting 1.6

IN PRACTICESettings 2– 4:With an upscale of the Setting Number the duration of thecut and thereby the speed of the cut increases.Settings 2 to 4 have a longer cutting duration each leadingto a more extensive cut and therefore to a more rapidresection.Settings 1–10:In Setting 1 there is only a very short break between theindividual cutting impulses which leads to a rapid cut withlimited coagulation (Fig. 13).The higher the setting, the longer the coagulation cycleand therefore the cutting interval (Fig. 14).UvoltageUvoltageCutting intervalcutting cyclecut duration setting 4Fig. 12: ENDO CUT Q with the longest cutting duration: Setting 4.A cutting interval consists of a cutting and a coagulationcycle (Fig. 13). It is defined as the period of time betweenthe beginning of one cutting cycle and the beginning ofthe next .Uvoltagecutting cyclecutting interval setting 1ttimettimeFig. 13: ENDO CUT Q with cutting interval at Setting 1: the coagulationcycle (blue) with the smallest possible cutting interval.OPERATIVE TECHNIQUESPreparation for polypectomy procedures andmucosal resectionElevating the lesioncutting cyclecutting interval setting 10Fig. 14: ENDO CUT Q with cutting interval at Setting 10: maximumduration of a coagulation cycle (blue) with the greatest possiblecutting interval.ttimeAn important precondition for a successful and safe polypectomyor mucosal resection is elevation of the lesion(the polyp or mucosa) so that it stands out clearly from themuscularis propria (lifting sign) using the electrosurgicalsnare (Fig. 15) (or by means of a submucosal injection, seepage 8 for further discussion). By increasing the distanceto the muscularis propria the risk of thermal damage orperforation can be decreased. In addition, the fact thatthe lesion can be elevated (lifting sign) is an importantdiagnostic indicator (cannot be elevated = indicative ofmalignity with infiltrative growth).Adjustments of the duration of the cutting interval serveto control the fractionated cut. A short cutting intervalfavors a more rapid cut, longer cutting intervals result in aslower and more controlled resection.With the help of the parameter “Cutting interval” theduration of the coagulation cycle (in the Expert mode, cf.page 5) can be extended using 10 different settings. Pleasenote that while the cutting interval will influence coagulation,the intensity of the coagulation is decisively influencedby the chosen effect setting (cf. page 6)!msmmpFig. 15: Elevating the polypabove the muscularis propriawith the help of the snareprior to ablation. m = mucosa,sm = submucosa, mp = muscularispropria.7

Submucosal injectionSubmucosal injection of lesions (for example with a physiologicalsaline solution) offers several benefits. Firstly, thisincreases the distance between the tissue requiring excisionand the muscularis propria (Figs. 16, 17). Due to theexcellent electric conductivity and the heat conductanceof the injected solution, the electric current applied willbe distributed evenly within the saline cushion. This leadsto a decrease in current density and to the creation of athermal insulation layer. The risk of perforation is lessened.Secondly, the lesion can usually be visualized better andgrasped more easily after submucosal injection. This particularlyapplies to lesions which are located directlybehind a fold or are not very elevated.Furthermore, in addition to the purely mechanical pressuretamponade created by the submucosal injection it isalso possible to initiate medicinal prophylaxis againstbleeding using vasoconstrictive substances.It is not imperative to carry out such preparations (as describedabove) prior to polypectomy procedures or mucosalresections and preparation will differ in different hospitals.The degree and type of preparation will vary dependingon the experience and technique of the operatingphysician and on the clinical findings.Placing the electrosurgical snareWhen positioning the electrosurgical snare it is importantto take account of various aspects to avoid complications(bleeding, perforation):The snare should be placed around the lesion parallelto the intestinal wall, pressing lightly against thewall; the snare should then be closed slowly and liftedup parallel to the intestinal wall (Fig. 18 a).It is important to avoid one-sided tissue contact ofthe snare tip to the intestinal wall (Fig. 18 b).Visual control of the grasped tissue is important: iftoo much tissue has been grasped (including part ofthe wall) the snare should be opened and less tissueshould be grasped (Fig. 19).It is important to avoid to much traction on theelectrosurgical snare as this will lead to mechanicalexcision of the lesion without coagulation and thereforeincrease the risk of bleeding.smmIImpIIIIFig. 16: Submucosal (sm) injection.The distance between mucosa (m)and muscularis (mp) is increasedafter submucosal injection ofliquid (blue).Fig. 17: With the submucosalinjection the risk of selectivethermal heating by the electrosurgicalcurrent (black arrows)is reduced.a correctb incorrect a correctb incorrectFig. 18: Positioning the snare. a) Elevating the polyp above theintestinal wall using the snare, b) wrongly positioned snare.Fig. 19: Controlling the amount of tissue grasped prior to carrying outthe resection: a) the tissue has been grasped correctly and elevatedusing the snare in the direction of the arrow, b) in addition to thelesion a part of the intestinal wall was also grasped.8

IN PRACTICESpecific features of snare electrodesSingle-strand (mono-filament) snares have a smaller areaof contact with the tissue compared to multiple-strand(multi-filament, twisted) snares with the same diameter,which results in reduced coagulation.The diameter of the wire influences the degree of coagulation.A smaller wire diameter will have a lower coagulationeffect and a greater cutting effect.Mono-filament snares are mechanically stiffer than multifilamentsnares, which makes grasping the tissue easier.Polypectomy procedures at the upper marginsPre-coagulationTo reduce the risk of perforation pre-coagulation withFORCED COAG is recommended when treating stalkedpolyps or polyps > 10 mm (cf. recommended settings).Small polypsPolyps which are smaller than 5 mm may be removed bybiopsy forceps.We recommend using the FORCED COAG mode whenablating polyps with hot biopsy forceps; it is also possibleto harvest tissue for histological examination at the sametime.In this procedure the polyp is grasped with the forcepsand clearly elevated from the intestinal wall with a slighttraction on the polyp.A coagulated area is created between the distal tip of thehot biopsy forceps and the ablation surface (Fig. 20).Stalked polypsStalked (pedunculated) polyps between 5–15 mm in size(polyp head) can be ablated using either the FORCEDCOAG mode or ENDO CUT Q (Fig. 21). The polypectomysnare should be positioned close beneath the head of thepolyp at a distance from the intestinal wall.As soon as coagulation becomes macroscopically visible atthe stalk, the snare should be continually retightened andrepositioned Fig. 22). Too intensive coagulation in thedirection of the polyp base increases the risk of perforationof the intestinal wall.Large stalked polyps (> 15 mm) are generally associatedwith a higher risk of bleeding. During the resection oflarge stalked polyps with ENDO CUT Q we recommendcarrying out bleeding prophylaxis either by submucosalinjection, electrosurgical preconditioning, or by clipping.IIIIIIFig. 20: Ablation of small polypswith hot biopsy forceps. Beforeactivating the coagulation currentthe polyp should be clearlyelevated from the intestinalwall (large arrow). The current(l, arrows) is flowing in thedirection of the polyp base.aFig. 21: a) stalked polyp in the colon after being grasped by the snare.b) slight coagulation at the base of the polyp after polypectomy(white area at 11 o’clock).bFig. 22: Cross-section of a stalkedpolyp. For the resection, thesnare (orthograde, gray circles)must be placed firmly aroundthe stalk of the polyp and continuallytightened and repositionedin order to coagulate theinlying blood vessels.9

The high-frequency current will also cause the stalk of thepolyp to shrink lengthwise (Fig. 23). It is therefore betternot to plan the line of resection too close to the intestinalwall.With very large stalked polyps it is often difficult to differentiatebetween the proximal end of the stalk and theintestinal wall. In these cases we recommend carrying outthe resection close to the head of the polyp.The resection of large, sessile, broad-based polyps is usuallycarried out as a partial ablation using a piecemeal technique.Different methods, for example using a snare or acap, are now used (please see the following chapter onEMR).With broad-based polyps it is not always possible to guaranteea complete resection of the polyp. Any polyp tissueat the base of the polyp still present after resectioning canbe removed using Argon Plasma Coagulation (APC).Sessile polypsSubmucosal injection is generally recommended whentreating sessile polyps in order to ensure that the polypsare sufficiently separated from the intestinal wall. Afterthe polypectomy snare has been properly positioned, thecutting mode ENDO CUT Q can be activated.During the cutting cycle the snare should be slowly tightenedand repositioned under slight traction by an assistant.However, if the snare is too tight this could lead toan abrupt severing of the polyp (mechanical severancewithout sufficient coagulation).After the resection is completed, the resected material canbe removed using any one of the commonly employedmethods (snare, gripper, net, trap, etc.) – the type ofremoval will depend on the size of the resected specimen.Endoscopic Mucosal Resection (EMR) at theupper marginsEMR with a snarePrior to EMR with a snare we suggest using APC to markthe area in which there is a suspicion of polyp or carcinoma.In EMR procedures with or without submucosal injectionthe lesion can either be removed in one piece “en bloc”(Fig. 24) or using a piecemeal technique.After placing the snare around the lesion it is important toclearly elevate the lesion from its foundation (lifting sign),either using only the traction of the snare or by means ofsubmucosal injection. This elevation is important diagnosticallyand as an important precondition for a successfuland safe mucosal resection.II I IIII I IIabFig. 23: Lengthwise shrinking of a stalked polyp.Fig. 24: Left: Large adenoma in the duodenum. Right: Slight coagulationat the incision margins after snare resection.10

IN PRACTICEThe snare with the lesion is elevated in the direction ofthe intestinal lumen, away from the muscularis propria.The cutting process can then be initiated.EMR using a capIn EMR procedures with a cap (Figs. 25 a – d) with or withoutsubmucosal injection it may be useful to mark thesize and the shape of the lesion using the electrosurgicalsnare (FORCED COAG mode) or by means of APC (ArgonPlasma Coagulation). This will improve orientation, allowingthe cap to be placed more precisely on the lesion,which will then be sucked into the cap. After the polyp hasbeen firmly grasped by the snare the cutting process is initiatedand the snare is slowly tightened simultaneously.EMR with needle instrumentsIf the EMR is carried out using an “en bloc” technique(Figs. 26 a – d), it helps if the line of resection is markedusing tiny points of coagulation prior to submucosalinjection. We recommend using the mode FORCED COAGfor such marking with needle instruments or Pulsed APCwith an APC probe.Subsequently, different needle instruments such as needleknives or hook knives together with ENDO CUT Q can beemployed for the resection of the mucosa.The lesion can then be resected either with needle instrumentsor using an electrosurgical snare.Due to the higher risk of perforation these EMR techniques(EMR with a cap or a needle instrument) should currentlyonly be carried out in interventional centers bypractitioners with sufficient experience.Recommended settings for ENDO CUT Q for the differentsurgery techniques please find in the enclosed inset.a bc dFig. 25: EMR with a cap, a) submucosal injection b) Placing the snare and positioning the cap c) Sucking in the mucosa d) Resection outside the capa b c dFig. 26: EMR with a needle instrument, a) marking the lesion b) Opening up the mucosa after submucosal injection c) Slitting open the mucosawith a needle electrode d) Resection of the lesion with a snare11

3 AVOIDING COMPLICATIONSComplicationsThe two most common complications after a polypectomyor a mucosal resection are bleeding, which can either bespontaneous (primary) or delayed (secondary), and perforations.It is important to differentiate between perforationswhich are due to a mechanical injury to the intestinal walland those which are created by thermal necrosis.The following chapter offers hints and pointers on how touse ENDO CUT Q to avoid complications.Intraoperative bleeding due to insufficient hemostasis(primary bleeding)Hemostasis during electrosurgical cutting depends essentiallyon two factors: on the chosen coagulation effect(effect setting) and on the mechanical traction by thesnare on the polyp. If the polyp is constricted too much bythe snare, then the polyp will be severed during the firstcutting cycle. Because of insufficient coagulation this canlead to bleeding in both cases.Postoperative perforation by electrosurgical currentIf no cutting occurs despite activation of the foot switch,the operating physician should on no account continue toactivate the foot switch. This could lead to a high energyoutput and subsequent thermal damage to the intestinalwall.Possible sources of the trouble can be wrongly set parametersor defective instruments.A two-stage or hidden perforation can result from toogreat an energy output at the base of the polyp, duringwhich a creeping necrotization of the intestinal wall mayoccur (Fig. 27).This risk can be reduced by submucosal injection or elevation,particularly of broad-based lesions.Resections should always be carried out under visual controlso that the resection can be cut short if the coagulationeffect at the base of the polyp is too great.Coagulation outside the direct cutting areaa) Constriction of the polypToo great an elevation of the polyp can result in extremeconstriction at the base of the polyp.Such a constriction of tissue can lead to higher currentdensities which may result in a coagulation and potentiallyto an incision at some distance from the snare (Fig. 28).b) Contact between the polyp and the intestinal wallContact between the polyp and the intestinal wall canlead to an uncontrolled flowing off the electric current.Together with high current densities at the points of contactthis may result in a thermal injury of the intestinalwall (Fig. 29).c) Unwanted contact of the snare and the intestinal wallAfter the resection has been concluded the snare must becompletely retracted into the insulated shaft so that if thefoot switch is inadvertently activated during the removalof the snare no further coagulation effects will occur.I I IIII I I I IIIIIIIIIIIIIFig. 27: Thermal injury to theintestinal wall due to a too highenergy output. The coagulatedarea is shown in gray/white).Fig. 28: The polyp was pulledtoo strongly into the lumen. Thisresults in high current densitiesand coagulation (gray/white) atthe point of constriction.Fig. 29: Thermal injury to theintestinal wall due to flowingoff of the electrosurgical currentvia the head of the polyp andthe creation of high currentdensities (arrows).Fig. 30: Any contact between theelectrosurgical snare and a metalclip must be avoided, as the highcurrent densities occurring atthe clip can lead to thermalnecrosis in the area around theclip.12

AVOIDING COMPLICATIONSContact between the snare and the metal clipsIf metal clips are used for hemostasis it is important toensure that no electrosurgical current can accidently flowoff via the metal clips during resection with the electrosurgicalsnare (Fig. 30).Depressing the foot switchIf the pedal of the foot switch is depressed only brieflyduring resection, there will be no coagulation cycle betweenthe cutting cycles. Only the cutting cycle will be activated.This can also lead to bleeding after resection. Theyellow foot pedal must therefore be continually pressedthroughout the procedure until the resection is complete.Defective instruments/accessoriesOnly connecting cables without any defects should beused.Loose connecting plugs can lead to the creation of arcs atthe connecting parts which could negatively affect thecontrol of the operative procedure. The cutting stagemight thus be prematurely interrupted, preventing anyfurther cutting.Faulty application of the patient plateThe area of contact between patient plate and skin mustalways be as large as possible. Any intraoperative lesseningof the contact, for example if the patient plate comesoff, can lead to thermal injury of the skin.Improperly placed electrodes or reusable silicon patientplates with a higher impedance can negatively influencethe effect of ENDO CUT Q.We recommend using disposable dispersive electrodeswhich activate integral patient safety systems in the ESUsuch as NESSY (Neutral Electrode Safety System), REM, etc..Note:For more general information on electrosurgerywe recommend the brochure “Basic Principles ofElectrosurgery” from ERBE Elektromedizin GmbH.With polypectomy snares it is important to ensure that thesnare can easily be opened via the snare shaft. On noaccount may defective polypectomy snares be used.If closure of the snare is no longer possible during thepolypectomy procedure, activation of the electrosurgicalgenerator must be immediately terminated, otherwisethere is a risk of perforation of the intestinal wall.13

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