Basic Instrumentation




With ubiquitous adoption of laparoscopic surgery in many surgical disciplines, a wide variety of laparoscopic instruments are available in operating rooms. Herein we describe commonly useful laparoscopic instruments as well as instruments specialized for retroperitoneal laparoscopic 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 in this book.


Dissectors and Graspers


A variety of laparoscopic grasping instruments are available. Instrument sizes vary in both diameter (3 to 10 mm) and length (20 to 45 cm). Although narrower instruments facilitate operations through smaller ports, they are less rigid and limited to single-action jaw movement compared with larger instruments, which can have dual-action jaw movement. Longer instruments, commonly referred to as bariatric instruments, are helpful in patients with a high body mass index or in cases with difficult access. Handle options include open ring, ratchet, pistol grip, coaxial, and bent wire handles ( 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. Atraumatic graspers use serrated tips that cause less damage to vital structures. Graspers with disposable padded tips are also available; these are atraumatic in their grip and avoid the crushing forces often seen with metal-tipped graspers. Both single-use and reusable graspers are available. Reusable instruments feature interchangeable instrument tips and handle pieces. Some reusable instruments can also be disassembled to allow cleaning.




Figure 3-1


Common instrument handle configurations include (A) open ring, (B) ratchet, (C) pistol grip, ( D and E ) coaxial, and (F) bent wire handles.



Figure 3-2


Common instrument tip configurations include (A) needle driver, ( B and C ) grasper (atraumatic and traumatic), (D) dissector, (E) scissor, and (F) cautery hook tips.


In addition to the rigid, straight graspers, more recent technical advances have led to the development of articulating laparoscopic instruments ( Fig. 3-3 ). These are available from a variety of manufacturers and can facilitate single-site surgery and other complicated laparoscopic procedures.




Figure 3-3


Articulating laparoscopic instrument (Cambridge Endo, Framingham, Mass.). Articulating laparoscopic instruments provide an additional axis of motion.




Scissors


Both single-use and reusable scissors with a variety of tip shapes (straight, curved, and hook) 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 without 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 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 ).




Figure 3-4


Ideal position of needle loaded on laparoscopic needle drive. The needle is positioned at the tip of the needle driver, grasped approximately one third of the distance from the swage with the tip of the needle canted away from the instrument.


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; longer suture lengths can be more difficult to tie. For extracorporeal tying, a longer suture should be used.




Figure 3-5


The laparoscopic knot pusher (A) facilitates laparoscopic knot tying (B) by allowing the throws to be made extracorporeally.


Several devices are available to assist with intracorporeal suturing, including Endo Stitch (Covidien, Dublin, Ireland) and Sew-Right (LSI Solutions, Victor, N.Y.). These instruments feature a specialized needle and passing mechanism that is designed to facilitate both suturing and knot tying. Suture Assistant (Ethicon, Somerville, N.J.) is more similar to a traditional needle driver in passing the needle through tissue but features a specialized suture and tying mechanism to facilitate intracorporeal knot tying. Endoloop (Ethicon) is a preformed loop of Vicryl or polydioxanone (PDS) 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.




Figure 3-6


Lapra-Ty instrument (Ethicon, Somerville, N.J.) [A] and application to suture (B) .


Although freehand suturing and knot tying are technically advanced skills, we generally prefer them over the suturing aids because they allow for more dexterity and finesse in movement as well as a much larger range of needle selection and suture material.




Vascular Clamps


Several instruments are available to assist with vascular control and clamping, including laparoscopic Satinsky clamps as well as bulldog clamps, which are inserted, applied, and removed with the aid of a specialized instrument ( Fig. 3-7 ).




Figure 3-7


A, Bulldog clamp. B, Laparoscopic clamping performed with a bulldog clamp.




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 best 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, N.Y.), and Diamond-Flex (Genzyme Surgical Products Corp., Tucker, Ga.), as well as disposable paddle retractors ( 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 ).




Figure 3-8


Retractor systems. A, The fan retractor houses several arrays that can be passed through a standard trocar and then opened to provide a wide surface for retraction. B, The PEER retractor (Jarit Surgical Instruments, Hawthorne, N.Y.) can be placed through a standard trocar and opened to provide retraction of organs, including the kidney, liver, spleen, and bowel, in a variety of situations. C, The Diamond-Flex Triangle retractor (Genzyme Surgical Products, Tucker, Ga.) is a 5-mm device that can be placed through a standard trocar. Once inside the abdomen, the handle can be tightened, pulling the tip into an angled, triangle shape with a large surface area for retraction. D, Endo Paddle retractor (Covidien, Dublin, Ireland).

Only gold members can continue reading. Log In or Register to continue

Sep 11, 2018 | Posted by in ABDOMINAL MEDICINE | Comments Off on Basic Instrumentation
Premium Wordpress Themes by UFO Themes