Tripolar Revisited

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Peter Dragonas, MD: I’m Doctor Peter Dragonas, an MD from Boston originally, where I spent 25 years at Harvard Medical School and associated hospitals and gynecology, gynecologic endoscopy and fertility and researched a lot of endometriosis. I’ll be in New York shortly and we’re here at the AAGL annual meeting and the world congress on endoscopy and enjoying a wonderful time, but particularly, we’re enjoying being reminded of the research done by great companies like ACMI in constantly trying to give us products that help us in our surgery and help serve the patients and the country’s population. 

The happiness particularly in infertility is immeasurable, but the happiness that comes from the surgeon’s point of view, particularly Doctor Michael Seitzinger, a renowned physician and inventor of endoscopic equipment. He hails from Wisconsin, from the country, I believe, of many lakes and music and all kinds of good things and good medicine.

Michael Seitzinger, MD: A lot of cheese.

Peter Dragonas, MD: And a lot of cheese and he’ll tell us even more and probably some football teams, at that. But at any rate, the most important thing is that he has invented some very, very important, shall we say, electrical, or he will describe what kind of bipolar / tripolar equipment can be used during laparoscopy and so we have to congratulate from the outset, Dr Seitzinger for his interest and development of new instrumentation and also congratulate companies like ACMI who have been with us for many, many years for their forwardness in taking the cue from this fine man in trying to help female medicine and the general gynecological delivery of healthcare. Thank you, doctor, for coming and being with us today.

Michael Seitzinger, MD: Thank you for having me. What I’m going to do basically is revisit the, what I call the tripolar. The initial concept back in the early ‘90s was such that we using a bipolar instrument to cauterize tissue and then bringing in a monopolar instrument to cut the tissue or scissors and the goal was to combine all the electrical sources into one, therefore the name tripolar.

Peter Dragonas, MD: Before we proceed, excuse me for cutting you off, why did we go from unipolar to bipolar?

Michael Seitzinger, MD: Well, the safety factor because the tissue that’s desiccated is between plus and minus on the electrical poles and all of that tissue is desiccated. Monopolar tissue travels through the body, through the energy source and back through the grounding pad. Now, if there was a problem, shorting out or so forth, you could burn a bowel down the road and you never do, so instead of using of a monopolar cutting device, at the time they came out with the EndoGIA which had a knife blade in the handle.

Peter Dragonas, MD: Is that like a Slezinger or along the same principle?

Michael Seitzinger, MD: No, it looks like two rows of staples, and then they had a knife. So basically what we did is design, actually Cabot Medical initially designed this. It’s an ACMI product.

Peter Dragonas, MD: Oh, I know them well.

Michael Seitzinger, MD: So we have a device that this was a standard bipolar instrument to plug into any electrosurgical generator, you don’t need a special generator for this, and so it desiccates the tissue. You activate it by stepping on the foot pedal. Once the tissue is desiccated, then you advance the knife and that will simply divide the tissue. Now it also acts as a grasper and I can show you it’s atriomatic, you can put it in your hand, it has a good grip, it does not slip off, and then the knife blade is always sharp for hysterectomies, myomectomies, inside the vagina. This is the 10mm version.

Peter Dragonas, MD: Is that a disposable instrument or is that recyclable?

Michael Seitzinger, MD: This is disposable at this time. I understand that they’re still working on a reusable model. What we did then, because being a champion of smaller portal entries, we designed . . .

Peter Dragonas, MD: Less trauma.

Michael Seitzinger, MD: Less traumatic. This is the new 5mm, which the tip is now very similar to the 10mm, it’s longer, and you have a much better grasping capability. Again, it’s atriomatic and the same nice weight in the handle. You can do everything with the 10mm . . .

Peter Dragonas, MD: It’s wonderful, it moves so easily.

Michael Seitzinger, MD: . . . and like I say, it’s atriomatic. It’s normally closed and now these are made for opening, you have to actually squeeze the handle to apply the pressure. It’s best if you have a bleeder, that you could actually apply this to the tissue, the bleeding tissue, leave it there and then deal with either suturing it or cauterizing it or whatever you might do. We also have a shorter model, the 10mm, for doing open procedures or getting the uterine arteries from a vaginal approach . . .

Peter Dragonas, MD: Yes, because you need a larger blade for a larger artery. You can’t do it with a very small blade . . .

Michael Seitzinger, MD: Well, this is fine.

Peter Dragonas, MD: . . . because it will bleed.

Michael Seitzinger, MD: I think the 5 will do it. Yeah, this is twice as long as the old one and I think that this may be able to handle almost as much as, this is the workhorse, this is for the myomas, that large uterus with the fibroids, but we do find we’re very excited about because now, because I think, because of probably, see what you think about this . . .

Peter Dragonas, MD: You know what really amazes me, Dr Seitzinger, is that this is a disposable instrument. I’d have a hard time throwing this away after a procedure. This is so beautifully built and so beautifully balanced and so easy to move the blades and the cutting device on it, it troubles me that we have to throw it away.

Michael Seitzinger, MD: Well, internationally, when we traveled a number of years ago showing this all over the world, everyone liked the concept except for the fact that you have to throw it away, and . . .

Peter Dragonas, MD: What's this button, is this to hold it?

Michael Seitzinger, MD: Yeah, that’s basically a locking mechanism. But you don’t need that because you want to release it, you don’t want to be tearing tissue so you just simply release it.

Peter Dragonas, MD: Well, interestingly enough, I agree with you 100%. It’s my experience that the smaller the portal under vision once you’ve made your initial entry through the umbilicus through a vertical incision, preferably for me it’s right through the center of the umbilicus because I’ve been doing that for twenty years, right through the center and it was hard to convince those people who made smiles on, around the umbilicus that they really were going through the long route.

Michael Seitzinger, MD: Right, the wrong route.

Peter Dragonas, MD: But anyway, the point is that once you can visualize what’s coming through, I’ve never had a complication putting a small portal in and I’ve spent some time with Dr Palter down at Yale with the 2mm laparoscope and the flexible laparoscope and doing laparoscopy almost in office, but nevertheless, the smaller instruments are being developed and we’re doing even finer work. We’re really, I hate to say it, it sounds awful, but we are plastic surgeons of the reproductive woman’s system and we need smaller and more refined instruments to do it and ACMI obviously is helping us sort that out. Do you disagree?

Michael Seitzinger, MD: No, I agree entirely. This will work as a fine dissector if you actually separate the blades slightly, you can actually cut with it. So once inside . . .

Peter Dragonas, MD: I don’t know if the camera can get this, but I’m going to separate the blades widely and I’m going to push the cutting blade through it so one can see that it exists. I’ve got to pull the knife back, separate the blades and then I’m forwarding the knife and you can see the knife slowly cutting through and obviously with the blades closed together, it does a very good clean-cut job. Razor cut, I take it.

Michael Seitzinger, MD: Oh, yes, very sharp. This will actually, if you separate the blades slightly, will act as a, the bipolar current through here will act as a cutting device without the knife, so I will incise over the vaginal cuff with a moistened towel or something in the vagina and actually make my incision in the vaginal cuff with the tripolar because it seals it as you’re cutting.

Peter Dragonas, MD: Let me ask you a very important question to my way of thinking. Does a gynecologist working in a distant hospital from a university setting have any fear in using this equipment whatsoever?

Michael Seitzinger, MD: No, no, because it’s safe, you’re seeing exactly what you’re doing and is what you get, basically. I mean, You’re seeing this very little spread of the current, you can actually watch the heat, it’s about 2mm to 3mm on either side of the blades. Yes, you need to make sure that the ureter is out just as in any type of procedure, in suturing or if you’re using a clamp, you need to watch out for those landmarks, of course.

Peter Dragonas, MD: Well, of course. Well everybody does whether they’re in a university hospital or in the, how you would say, freestanding clinic 500 miles away from the biggest center. I mean . . .

Michael Seitzinger, MD: We’ve used this in Russia, Singapore, Taipei, Australia, the UK, Gotberg, Stockholm, Madrid, Seville, Bologna, so we do . . .

Peter Dragonas, MD: Do you think we Americans are doing a good job at keeping up with the requirements for this kind of new technology and new instrumentation or is it coming mainly from other countries?

Michael Seitzinger, MD: No, it’s, it’s US based, I feel. After we . . .

Peter Dragonas, MD: So then we should be very proud of our accomplishments.

Michael Seitzinger, MD: After we patented this, there are now probably five or six different instruments very similar to this.

Peter Dragonas, MD: I understand. How many hours a week in your professional life do you spend on instrument development? Or is it all kept in your mind?

Michael Seitzinger, MD: It’s in my mind, but then getting it to the marketing person, to the engineer, it’s endless procedure.

Peter Dragonas, MD: And how enthusiastic is ACMI in working with you on your ideas?

Michael Seitzinger, MD: Oh, they’re very, I’ve got a new product that keeps a scope from fogging that I just presented to ACMI. They’re going to take a look at this and see if it might be something they want to feature in their product line.

Peter Dragonas, MD: So if a physician even way out has some ideas about developing instrumentation, is it all right to tell them to be in touch with you?

Michael Seitzinger, MD: Absolutely.

Peter Dragonas, MD: And you can help them? And where are you located specifically?

Michael Seitzinger, MD: Green Lake, Wisconsin, and my e-mail is mseitz@vbe.com, and they can e-mail. I’ve actually got a program that I put together on how to develop new instrumentation. So I show it to Kiwanis groups because it doesn’t have to be medical.

Peter Dragonas, MD: Well, no, I think the public should know, as I said yesterday in a talk, that an educated patient is the best patient and I tell my patients in my practice for years taught by Robert Kistner back in Boston who I was affiliated with for ten years and more and was my professor, that tell your patients to read about what they’re, what’s happening to them and if they don’t know before they come to the office, give them literature to take and read and call you back so that you get a patient that is helping themselves understand what you’re also trying to teach them. So it’s an educational procedure that goes back and forth and . . .

Michael Seitzinger, MD: Well, our part is keeping up with the patient because they are on the Internet.

Peter Dragonas, MD: I think the American patient is a very fortunate patient and very little should be taken for granted, like take ACMI, the work that goes behind the scenes in order to develop not only the, an instrument that’s efficient, effective, clean, sterile, with no, hopefully no problems resulting from the instrument, but also the cost-effectiveness so it can be used on the patients.

Michael Seitzinger, MD: This is why I developed this because in my original ablations, we were using a bipolar and then using a CO₂ laser to cut and then you had to keep the plume out then you waited for the abdomen . . .

Peter Dragonas, MD: Oh, I remember those days very well.

Michael Seitzinger, MD: . . . or for a hysterectomy with this.

Peter Dragonas, MD: And the other with it. Can I ask you a question? What does it cost, do you think?

Michael Seitzinger, MD: You know, I’m not certain, I think about $120, $150 for these.

Peter Dragonas, MD: For either one of these?

Michael Seitzinger, MD: Yes, I think they’re priced about the same. The nice part is the hysterectomy now is about twenty to thirty minutes, even a large fibroid, I mean . . .

Peter Dragonas, MD: What would you say, in closing, is the chief use of this, of these two instruments for any gynecologic endoscopist? Or surgeon, for that matter doing gall bladder work?

Michael Seitzinger, MD: General surgeons have used this extensively for like taking the short gastric center on misandiaplactation, general surgeon use on appendectomy, I mean any procedure you can think of, this has an application for.

Peter Dragonas, MD: I wanted to ask you are you university affiliated or do you have a freestanding place?

Michael Seitzinger, MD: No, I’m with the University of Wisconsin. I’m a Clinical Assistant Professor.

Peter Dragonas, MD: Oh, congratulations and we hope the next time we talk that you’re a full professor.

Michael Seitzinger, MD: Thank you very much.

Peter Dragonas, MD: You’re very kind and very informative and I want to again congratulate you on your contributions to our profession and particularly gynecological endoscopy and your patients are very fortunate to have you, I know that.

Michael Seitzinger, MD: Thank you very much.