Laparoscopic surgery uses long-pencil like instruments that fit through small cuts in the abdominal wall instead of large incisions required during open operations.
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Laparoscopic instruments are used along with a laparoscope, which is a thin telescope fitted with a cold light source and a video camera. Inert gases like carbon dioxide are used to inflate the abdominal region which increases the distance between the organs and the abdominal wall thus enlarging the operating field. Common instruments used during laparoscopic procedures include a: laparoscope, needle driver for suturing, trocar, bowel grasper and surgical mesh.
Surgical scopes are one of the oldest instruments used by medical practitioners since ancient times. Modern surgical laparoscopes used for minimally invasive procedures are a far cry from the simple hollow tubes that gradually developed to include lenses for magnified vision. Today, scopes are more like an apparatus with multiple parts that include a CCD camera, viewing device, lens cleaner, and an energy-supply device.
A needle holder is used by laparoscopic surgeons to hold suturing needles when closing wounds. Forming slip-knots to close wounds and surgical incisions requires precise skills. Suturing can often be tricky to use owing to the property of &#;memory&#; which causes tissue to resist deformation. Needle holders have three parts &#; the jaws, joints, and handles. The instrument is classified as straight or curved depending upon the shape of the jaws.
Along with the probe, scalpel, and cannula the trocar is one of the oldest implements used by medical practitioners. A trocar is shaped like a pen and has a sharp triangular point. Trocars are typically placed inside hollow cannulas and introduced inside body cavities to assist in draining fluids. Trocars are now referred to as both the initial entry device as well as the hollow cannula used during the operation. These instruments play an important role in laparoscopic surgery. Instruments such as scissors and graspers are introduced using surgical trocars.
A bowel grasper is used during minimally invasive bowel surgery. The graspers are maneuvered through incisions that are usually no larger than 5 mm. The advantage with using laparoscopic graspers is that they enable the surgeon to grasp and manipulate abdomen tissue with precision without having to cut open the abdomen. The graspers facilitate observation, excision, and biopsy procedures.
Hernia mesh is an implantable device that serves as scaffolding for your natural tissue to grow into and hence reinforce the area. The mesh itself only provides minimal support. It is your own tissue that is ultimately responsible for the repair. There are many different types of surgical mesh that can be used to repair hernias and other defects of the musculoskeletal system.
The journey of laparoscopy, which is now reaching single-incision and robotic surgery, began with our quest to find ways to reduce operative morbidity. Since those first steps were taken, gynaecological surgery with the use of minimally invasive techniques continues to change rapidly. With computerised design and microchip-controlled safety features, the laparoscopic surgeon is dependent on the equipment and needs to understand the electromechanical function of the instruments. In this changing environment, it is vital to understand the characteristics of the commonly used surgical instruments. The basic equipment essential for any laparoendoscopic procedure includes: endoscope, camera, light source, video monitor, insufflator, trocars and surgical instruments. However, there are many variants of each available.
The cost effectiveness of disposable versus reusable instruments is a subject of debate. The choice of the instrument is multifactorial and depends on function, reliability and cost. So, during most laparoscopic procedures, a combination of disposable and reusable instruments is used. Frequently, disposable trocars and scissors are used, while reusable instruments can be graspers, coagulation spatula/hook and needle drivers. The commonly used laparoscopic instruments are described below.
These allow uterine positioning and expand operating space. Several uterine manipulators are available &#; the HUMI® (Cooper Surgical), the RUMI® (Cooper Surgical), Spackman, Cohen, Hulka, Valtchev, Pelosi and Clearview® (Endopath). Some are reusable while others are disposable. Most come with a channel to perform chromotubation; however, some (such as Hulka tenaculum and Pelosi) lack this channel. With 210˚, Clearview has the greatest range of motion in the anterior-posterior plane. Hulka tenaculum, Spackman&#;s and Cohen&#;s have a straight shaft, hindering their range of motion and limiting their use in advanced laparoscopic procedures.
This is a specially designed needle with a blunt-tipped, spring-loaded inner stylet and a sharp outer needle, used to achieve pneumoperitoneum while performing closed laparoscopy. It is available in disposable and reusable form, with 12cm or a 15cm length.
Most injuries in minimally invasive surgery are associated with primary port insertion, leading to an unresolved debate on the benefits of various entry techniques (open, closed or direct entry). There is no evidence that any single technique is better in preventing major vascular or visceral complications, though there is a higher risk of failed entry with closed entry. The most recent Cochrane review concluded there is a lower risk of vascular injury with the direct entry in comparison to use of Veress needle.
These are used to create small passageways through the abdominal wall and are available in different textures (see Figure 1). Disposable and reusable trocars in various sizes are available and share the following common parts:
The telescopes used in laparoscopy are available in sizes ranging from 2mm up to 12mm. The 10mm size is the one most commonly used in gynaecology. Similar to a hysteroscope, a laparoscope can come with an angle of view such as 0˚, 30˚ or 45˚. In an angled-view scope, the direction of vision points away from light source attachment. The 0˚ telescope offers a forward view corresponding to the natural approach and is preferred by most gynaecologists. It is useful if a less-experienced assistant is available. The 30˚ telescope can be rotated to enlarge field of view and can be advantageous for complicated cases. The 45˚ telescope is useful in single-incision laparoscopies, but is not commonly available. Every laparoscope has an engraved number by the eyepiece that specifies the viewing angle.
The commonest diameter for laparoscopic instruments is 5mm, though they range from 2&#;12mm. The narrower diameter (less than 5mm) instruments have less shaft rigidity and therefore are more flexible and more fragile than the wider versions. Standard instruments&#; length ranges from 34&#;37cm. In bariatric patients or for single-site laparoscopy, 45cm-long instruments are useful.
Most laparoscopic instruments offer only four degrees of freedom of movement: in/out, up/down, left/right and rotation. In addition, certain devices called articulating/roticulating instruments offer angulation at their tips, which can be particularly useful in achieving triangulation while performing single-incision laparoscopy.
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Graspers and scissors usually have an insulated sheath, a central working device, a handle and a rotating capability at the working end.
Ringed handles are similar to the conventional ring handle found on most needle holders used in open surgery. They can be in line or directed 90˚ in relation to the working axis. Some handles are in between these two:
The handles come with different types of ratchets that provide a locking mechanism.
Scissors with curved tips, analogous to Metzenbaum, are commonly used. Most endoscopic scissors can also be attached to the electrosurgical unit. Scissors are produced with variety of tips.
Grasper jaws (see Figure 2) are either are single action (one fixed jaw and one articulated jaw) or double action (both jaws articulated). Single-action jaws close with a stronger force ideally suited for an instrument such as a needle driver. Double action allows the jaws to open wider, so they are better suited as a dissection tool. Numerous grasper variants exist, with the inner side of the jaws having different surface properties, depending on the intended use:
Equally, laparoscopic tenacula are also available with single-toothed and doubletoothed jaws.
Many styles of needle drivers are available and selection largely depends on surgeon&#;s preference. The jaws are either curved or straight. They commonly have a flat or finely serrated grasping surface, enabling them to grasp the needle in all directions. Certain needle-holders (termed self-righting) have a dome-shaped indentation inside their jaws that automatically orientates the needle in a perpendicular direction, thus making it easier to grasp the needle. However, if there is a need to load the needle at an oblique angle, the indentation can make it harder. The needle drivers also have various types of handles (such as finger grip, palm grip, pistol grip) as described previously.
Myoma screws are in the shape of a probe with a corkscrew tip. They are frequently used during myomectomy.
The suction irrigator is a multipurpose piece of equipment. Most use a trumpet valve but some have a sliding valve. The irrigation system can be powered by various mechanisms including pressure bag or a pump. Omentum, fallopian tube or bowel can get drawn into the suction probe and care must be taken to release the attached tissues gently.
The aspiration needle is a 16/22-gauge needle used for aspiration and injection of fluids.
There are two types of knot pushers available: the closed-end and the open-end knot pusher. Both have their advantages and disadvantages.
Energy sources include monopolar, bipolar, advanced bipolar, harmonic, combined and morcellator devices. Monopolar devices are commonly used in endometriosis resection and for incising the vaginal cuff during laparoscopic hysterectomy. Various types of monopolar hooks and spatula are available and most scissors have an attachment to connect monopolar lead.
Bipolar devices contain the continuous waveform electrical current between the jaws of the forceps and hence reduce the chances of damage to adjacent tissue. They achieve tissue sealing and haemostasis by thermal coagulation, though they lack the ability to cut. The classic bipolar device is the Kleppinger bipolar forceps. Several types of bipolar devices, many of them in form of graspers, are now available.
The surgical evolution of the energy devices, particularly with advanced bipolar features, has been the central point in exponential growth of laparoscopic procedures. The gain in popularity of these devices can be gauged by the fact that they are sometimes now used for open surgery and even vaginal surgery.
Bipolar devices (such as LigaSure&#;, Gyrus PKS&#; and EnSeal®) provide haemostasis for vessels up to 7mm. They provide a low voltage, have an impedance-based feedback that modifies the energy delivered and tissue temperature is regulated to be below 100°C. The bipolar energy thus delivered denatures the collagen and elastin in vessel walls. Denatured tissue, tissue apposition and pressure seal the vessel walls in a process called coaptive coagulation. In comparison to the traditional bipolar instruments, these devices have reduced thermal spread, diminished charring and reduced sticking. However, some of these devices require a specialist electrosurgical unit and they are costly.
LigaSure (Covidien) provides a continuous bipolar waveform and has an integrated cutting mechanism. GyrusPK (Gyrus ACMI) delivers a pulsed bipolar waveform that allows tissue and device tip to cool during the energy off phase, but lacks the ability to cut. Enseal (Ethicon) has nanometre-sized conductive particles that direct the energy and control temperature between the jaws. Like LigaSure, it is multifunctional, with an I-Blade&#; to cut the sealed tissue.
Harmonic devices have a piezoelectric crystal in their handpiece that converts the electrical energy into ultrasonic energy. This energy is delivered to the active blade at the tip of the instrument causing it to vibrate at 55 000Hz. The tip of the device cuts mechanically with a degree of collateral thermal coagulation used for haemostasis. There is no active current in the tissue. The advantage of harmonic devices is lower temperature (<80°C) as compared to other energy devices, hence reduced thermal spread and less charring. As a result of mechanical vibrations, in lower density tissue the intercellular water is vaporised at lower temperatures (<80°C) causing a &#;cavitation effect&#; that can help in dissection by separating tissue layers. They are FDA approved for <5mm vessel sealing. Though harmonic devices operate at low temperatures, the active blade of the device becomes very hot and can remain so for some time. Care should be taken not to touch the vital structures with the jaws of the device for several seconds after activation.
Thunderbeat® (Olympus) combines both advanced bipolar electricity and ultrasonic energy in a single, multi-functional, handactivated instrument and can potentially reduce the surgical time.
Morcellators can be important tools for specimen removal during procedures, such as myomectomy, when a large amount of tissue is retrieved laparoscopically. Various types of morcellators are available on the market. The key safety maxim is to keep morcellator tip close to abdominal wall, to pull the tissue into the morcellator and not push the morcellator into the tissue. Morcellators require ports that are bigger than 5mm. Morcellation has recently been in news with a US Food and Drug Administration safety communication in swiftly followed by new and/or revised guidelines, including a joint statement by AGES and RANZCOG. To prevent tissue dissemination, power morcellation in an isolation bag has been proposed. Recently, an in-bag morcellation device (Alexis&#; Contained Extraction System) has also been made available.