Transperitoneal

Laparoscopic instrumentation has not changed much since the introduction of the Veress needle in 1947 [1]. The Veress remains widely used as a safe and efficient access to the peritoneal cavity while causing minimal trauma [2]. It is a 2 mm needle with a spring‐loaded blunt obturator that is hidden during penetration of firm structures, such as fascia or skin (Figure 80.1). The blunt obturator deploys beyond the beveled edge of the needle when encountering softer, mobile structures such as bowel or intraperitoneal organs. Although a blind access technique, several tests such as aspiration, monitoring of insufflation pressure, and the “saline drop” tests can be used in combination to confirm entry into the peritoneal cavity [3] (Video 80.1).

For those uncomfortable with blind access or for patients with extensive previous abdominal surgery, the Hasson technique, open entry through a small incision with direct visual entry, provides a nearly failsafe alternative. Special blunt‐tipped camera Trocars are manually deployed upon confirmation of entry for camera placement and insufflation. These Trocars will be described in subsequent sections [1].

Retroperitoneal

The retroperitoneal space is only a potential space, making it ineffective for access and initial insufflation with a Veress technique. Access can be achieved by the Hasson technique with the use of a balloon dilator under laparoscopic vision. Although older reports describe filling a surgical glove or condom with air or saline once the proper space is entered, modern dilating balloons allow for manually controlled dilation with air while still maintaining visualization with a laparoscope [4]. Balloons are typically either spherical or oval in shape (Figure 80.2). Once the potential space is created correctly, the balloon port is switched to a traditional Hasson port to prevent loss of insufflation and dislodging.

Hasson

Usually used for the camera Trocar, Hasson Trocars are deployed into the access site created by the Hasson technique. They come in either a wedge/plug configuration or with a small‐volume intracorporeal anchoring balloon. These additions to the simple cylindrical Trocar are essential for open or Hasson port placement to prevent constant loss of pneumoperitoneum and dislodgement of the port, as the size of the fascial incision is larger than with a puncture technique. To prevent loss of pneumoperitoneum during instrument exchange, these Trocars have an internal rubber diaphragm.

Visual entry

Visual entry Trocars are cylindrical in shape and generally have a clear sheath and obturator with a dilating cone tip. The obturator is unique in that it will allow a 10 or 5 mm laparoscope lens to fit inside and visualize entry through the layers of the abdomen (Figure 80.4). The Trocars’ anti‐slip mechanism is such that since no fascial incision is made upon placement shear forces are stronger and there are small ridges on the surface of the outer sheath to hold it in place. To prevent loss of pneumoperitoneum during instrument exchange, these Trocars have an internal rubber diaphragm.

Reusable

Aesculap (Center Valley, CA, USA) offers a set of reusable, metal Trocars ranging from 3.5 to 12 mm in size (Figure 80.5). A series of reusable nipples and a mechanical internal one‐way valve prevent loss of pneumoperitoneum during instrument exchange. These Trocars are deployed using a screw‐technique, employing a threaded screw around the outside of the Trocar that both dilates and anchors the Trocar during surgery.

Internal dilating

The Step™ system (Medtronic, Minneapolis, MN, USA) is a radially dilating system of bladeless Trocars that are initially deployed by Veress needle. The Trocars dilate to full working size by placement of an internal dilator which opens the expandable Trocar sheath. This offers the advantage of minimal trauma to the abdominal wall and the small Trocars can be expanded to a larger diameter intraoperatively without the need to remove and replace [7]. Radially dilating Trocars have the smallest defect size when compared to single and triangular cutting bladed Trocars, but required the greatest insertion force [8].

Of note, there are a variety of other Trocars that have been developed and used for single‐port and robotic surgery that will not be discussed in this chapter.

Rigid endoscopes

Rigid endoscopes are the traditional lenses used to transmit light from the intracorporeal cavity to an image‐processing camera. They incorporate a separate fiber‐optic channel to transmit light into the body along the outer edges of the lens. Currently, these lenses offer different degrees of angulation (0–45°) and increasing size, from 2.7 mm “needlescopes” to standard 10 mm lenses for laparoscopic procedures. Generally, increasing the angle and decreasing the overall diameter diminishes image quality. On average, rigid endoscopes provide a 70° visual field. These lenses require a separate “camera” and light‐source cable attached to the extracorporeal laparoscopic tower to provide image transfer and light.

Near‐infrared technology

This technology requires injection of a fluorophore (commonly indocyanine green or ICG) that preferentially deposits in vascular tissues. A variety of different light sources can be used to excite the fluorophore and cause it to emit light. This light is then preferentially detected using one of several optical filters, highlighting the desired target tissues. In urology, the most common use for near‐infrared technology is in identifying renal tumors and ureters.

Narrow‐band imaging

Narrow‐band imaging uses wavelengths specific for limited green and blue visible light to highlight vasculature of mucosal surfaces. Although primarily used in endoscopic procedures, many image‐processing platforms used in laparoscopy incorporate this technology.

Three‐dimensional imaging

3D imaging was popularized in surgery primarily by the da Vinci® surgical system. The da Vinci® system utilizes a binocular lens and camera that projects through two separate eyepieces into a surgeon console. This concept has been applied to laparoscopic surgery through binocular surgeon headsets. While studies have shown that the 3D systems improve surgeon performance, they have not been widely accepted or utilized due to reports of dizziness, operator discomfort, technological complexity, and high cost [10–12]. For laparoscopic surgery, single screen‐suspended or set‐top monitors have been used to display 3D images (see Display). Early versions of 3D imaging were limited to standard definition (SD), but newer products offer HD quality of 3D images.

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