Basic instrumentation

The ubiquitous adoption of laparoscopic, and more recently, robotic surgery in many surgical disciplines has resulted in a wide variety of laparoscopic and robotic instruments. Herein we describe commonly used instruments in both transperitoneal and retroperitoneal laparoscopic and robotic urologic surgery. We focus our discussion on the following areas: graspers, scissors, needle drivers, retractors, energy instruments, suction and irrigation devices, and extractors. Access ports, closure devices, laparoscopes, and other instruments such as staplers and clip appliers are discussed elsewhere.

Dissectors and graspers

A variety of laparoscopic grasping instruments are available. Sizes vary in diameter (3 to 10 mm) and length (20 to 45 cm). Although narrower instruments facilitate operating through smaller ports, they are less rigid and limited to single-action jaw movement compared with larger instruments with dual-action jaw movement. Longer instruments, commonly referred to as bariatric instruments, are helpful in obese patients or in cases with difficult access. Handle options include open ring, ratchet, pistol grip, coaxial, and bent wire ( Fig. 3.1 ). Handles are available with or without locking mechanisms. Grasper tips are available in a variety of shapes and sizes ( Fig. 3.2 ). Traumatic graspers use toothed forceps to attain a firm grasp on tissue but can damage it. The tenaculum is a sharp-toothed instrument adopted from gynecologic surgery that is useful in retracting the prostate during simple prostatectomy. Atraumatic graspers use serrated tips that cause less damage to vital structures. Graspers with disposable padded tips are also available and lack the crushing forces often seen with metal-tipped graspers. There are a variety of robotic-specific graspers with various grip strengths, as well as the Force Bipolar grasper (Intuitive Surgical, Sunnyvale, CA), which allows the user to increase the grip strength of the instrument with the foot pedal. Both single-use and reusable graspers are available. Reusable instruments feature interchangeable instrument tips and handle pieces. Some reusable instruments can also be disassembled for cleaning.

In addition to rigid straight graspers, articulating laparoscopic instruments have more recently been developed ( Fig. 3.3 ). They are available from a variety of manufacturers and can facilitate single-site surgery and other complicated laparoscopic procedures.

Scissors

Both single-use and reusable scissors with a variety of tip shapes (straight, curved, hooked) are available. Most scissors can be connected to monopolar cautery devices to facilitate simultaneous ligation and coagulation. In addition, the scissor tips can be useful as a monopolar dissector by not operating the scissor action. The instrument shaft is insulated to prevent damage to surrounding structures.

Needle drivers and suturing instruments

Laparoscopic needle drivers are available in a variety of tip configurations (straight, curved, self-righting), insert types (carbide, serrated), and handles (finger, palm, pistol grip), whereas the needle driver configuration is driven by surgeon preference. Proper positioning of the needle in the jaws of the driver is critical to successful manipulation of the suture needle. Specific situations may vary, but in general, the needle is ideally positioned in the tips of the jaws, pointed away from the body of the instrument, and gripped one-quarter to one-half of the way along the curve ( Fig. 3.4 ). Some laparoscopic and robotic needle drivers contain a scissors near the base of the instrument that allows the user to cut the suture without changing instruments.

Knots may be tied intracorporeally with a needle driver and grasper or extracorporeally with the assistance of a laparoscopic knot pusher ( Fig. 3.5 ). For intracorporeal tying, suture tails should be trimmed to 7 to 12 cm as longer suture lengths can be more difficult to tie. For extracorporeal tying, a longer suture should be used.

Several devices are available to assist with intracorporeal suturing, including Endo Stitch (Covidien, Dublin, Ireland), SEW-EASY, and SEW-RIGHT (LSI Solutions, Victor, NY). These instruments feature a specialized needle and passing mechanism that are designed to facilitate both suturing and knot tying. Suture Assistant (Ethicon, Somerville, NJ) is more similar to a traditional needle driver in passing the needle through tissue, but it features a specialized suture and tying mechanism to facilitate intracorporeal knot tying. Endoloop (Ethicon) is a preformed loop of VICRYL or polydioxanone with a slip knot that can be used to efficiently ligate structures. LAPRA-TY (Ethicon) is an alternative to intracorporeal knot tying. Instead of tying a knot, an absorbable clip is applied to a tensioned 2-0, 3-0, or 4-0 VICRYL suture ( Fig. 3.6 ). LAPRA-TY can prove particularly useful if a suture breaks and the end becomes too short to tie.

Although freehand suturing and knot tying are technically advanced skills, we generally prefer them over suturing aids because they allow for more dexterity and finesse in movement in addition to having a much wider range of needle selection and suture material. In certain circumstances, the use of a looped barbed suture obviates the need to tie down the suture with a knot.

Vascular clamps

Several instruments are available to assist with vascular control and clamping, including laparoscopic Satinsky clamps and bulldog clamps, which are inserted, applied, and removed with the aid of a specialized instrument ( Fig. 3.7 ). In robotic surgery clamps can be applied either through the assistant port with a laparoscopic instrument or by using robotic graspers. Notably, graspers for the current version of the da Vinci Single Port Robot (Intuitive Surgical, Sunnyvale, CA) do not have the grip strength to open the jaws of many vascular clamps. Clamps may need to be placed laparoscopically in these cases. If a case does not lend itself to the use of vascular clamps, vessels can also be controlled with a vessel loop and sliding Hem-o-Lok clip (Teleflex Surgical, Morrisville, CA) or Rumel tourniquet.

Biopsy forceps

Laparoscopic biopsy forceps are available in 5- and 10-mm sizes.

Retractors

Although proper patient positioning and insufflation are critical first steps in exposing the operative field, intracorporeal retraction is often needed to displace organs for optimal visualization. Graspers can be used safely in most situations, but they are not appropriate in all cases and may damage organs or important structures.

A variety of laparoscopic retraction instruments are available, including the fan, PEER (Jarit Surgical Instruments, Hawthorne, NY), and Diamond-Flex (Genzyme Surgical Products Corp., Tucker, GA), as well as disposable paddle retractors such as the REVEEL (RETRACTION Ltd, Hong Kong) ( Fig. 3.8 ). Once the retractor is positioned, the assistant can either maintain the position, or the instrument can be secured to an extracorporeal holding system ( Fig. 3.9 ).