Laparoscopic Instrumentation 1

Summary

In this enlightening presentation, Dr. Janet Caron, a distinguished lecturer appointed by the Philippine Society of General Surgeons, delves into the essential tools and devices integral to minimally invasive laparoscopic surgeries. The lecture unfolds in three segments, focusing on access devices like the Veres needle and trocar cannula system, the intricacies of laparoscopic hand instruments, and a look at the components of the laparoscopic tower. From describing the spectrum of hand instruments—like graspers and dissecting scissors—to distinguishing between reusable, disposable, and reposable tools, Dr. Caron highlights crucial aspects of the instrumentation used during procedures, ensuring surgical efficiency and safety.

Highlights

• Dr. Janet Caron emphasizes the significance of proper laparoscopic instrumentation for efficient surgeries. 🌟
• The lecture explores fundamental laparoscopic access devices like the Veres needle and trocar cannula. 🔧
• An array of laparoscopic hand instruments, each with unique functionalities, is thoroughly reviewed. 🛠️
• Differences between reusable, disposable, and reposable instruments are crucial for optimizing surgical costs. 💰
• The presentation helps understand the laparoscopic tower components necessary for seamless operation. 🏢

Key Takeaways

• Dr. Janet Caron introduces the essential devices for laparoscopic surgery, enhancing surgical precision and safety 🎯.
• Understanding the Veres needle and trocar cannula system is crucial for gaining access during procedures 🚪.
• Laparoscopic hand instruments vary with their interchangeable parts and functionalities, made to adapt to different surgical needs 🤹‍♂️.
• Reusable, disposable, and reposable instruments offer diverse options for surgical procedures, balancing cost and functionality ⚖️.
• Comprehending the parts and mechanisms of the laparoscopic tower is vital for successful minimally invasive surgery 🔍.

Overview

Dr. Janet Caron opens by acknowledging her role in enlightening fellow medical professionals on laparoscopic tools and devices. With her clear and detailed explanations, she endeavors to enhance practitioners' understanding of minimally invasive surgical equipment, ensuring proficiency in laparoscopic procedures.

The presentation delves into vital laparoscopic instruments, beginning with access tools like the Veres needle and the advanced trocar cannula system. Each tool's design and application are dissected, showcasing their critical roles in the entry and execution of surgical techniques safely and effectively.

Highlighting the varied types of hand instruments and their capabilities, Dr. Caron also sheds light on the importance of choosing between reusable, disposable, and reposable instruments. This distinction aids in balancing surgical costs and instrument efficiency, making it a significant consideration in surgical practices.

Chapters

• 00:00 - 00:30: Introduction and Goals Dr. Janet Caron introduces herself as one of the lecturers for the session, organized by the subcommittee in minimally invasive surgery of the Philippine Society of General Surgeons. The focus of her lecture will be on laparoscopic equipment and instrumentation, aiming to aid participants in performing laparoscopic surgical procedures. The goal by the lecture's end is to equip participants with the necessary knowledge for such procedures.
• 00:30 - 01:30: Lecture Overview and Access Devices The chapter 'Lecture Overview and Access Devices' discusses the appropriate application of various minimally invasive surgical (MIS) instruments.
• 01:30 - 06:30: Hand Instruments The chapter discusses 'Hand Instruments' used in medical procedures, particularly focusing on those used within the workspace. It covers various types of instruments including dissectors, graspers, scissors, suction and irrigation devices, retractors, and instruments for suturing and knot tying. Additionally, it briefly touches upon the eight basic components of a laparoscopic tower which includes video monitors and a laparoscope.
• 06:30 - 10:00: Insulated and Non-insulated Instruments The chapter discusses various medical instruments, specifically focusing on the differentiation between insulated and non-insulated types. Essential tools listed include a camera, video processor, light source, light cable, and gas insulator. The chapter also mentions an irrigation system and highlights two key access devices, emphasizing the 'various needle,' invented by Hungarian internist Jonas Veres. This needle comprises an outer cannula with a beveled needle point for tissue penetration and an inner component, suggesting its detailed structure and function.
• 10:00 - 11:00: Conclusion The conclusion chapter discusses a specialized medical device known as a stylet, which is equipped with a spring mechanism. This stylet is designed to respond to pressure changes when it crosses the abdominal wall into the peritoneal cavity. It features a lateral hole that allows carbon dioxide gas to enter the abdominal area, creating a pneumoperitoneum essential for certain medical procedures. The stylet is available in different lengths, such as 80 mm for very thin patients and 120 mm for obese patients, to accommodate various body types.

Laparoscopic Instrumentation 1 Transcription

• 00:00 - 00:30 greetings fellow doctors I am Dr Janet Caron and I'm very much privileged to be one of the lecturers for today I was tasked by the subcommittee in minimally invasive surgery of the Philippine Society of general surgeons to discuss to you the laparoscopic equipment and instrumentation hopefully this lecture will be helpful as you do your laparoscopic surgical procedures we aim at the end of this lecture the participant should be able
• 00:30 - 01:00 to describe and discuss the proper application of the varied Mis instrumentation the participant also should be able to identify and describe the basic operation of the different elements of the laparoscopic Tower this lecture is divided into three parts first devices used in gaining and maintaining access which includes your various needle and the trar canula
• 01:00 - 01:30 system second is your hand instruments that we use in performing procedures within the workspace which includes the dissectors graspers cissors suction irrigation devices retractors instruments used for suturing and not tying thirdly the eight basic components of the laparoscopic Tower consisting of video monitors laparoscope
• 01:30 - 02:00 camera video processor light source light cable gas insulator and your Su irrigation system as earlier mentioned there are two access devices that you should be familiar with first the various needle which is invented by Jonas veres a Hungarian internist it consists of an outer canula with a beveled needle point cutting through tissues inside the canula is an inner
• 02:00 - 02:30 stylet which is loaded with a spring that Springs forward in response to the sudden decrease in pressure encountered upon crossing the abdominal wall and entering the peronal cavity the lateral hole on this tilet enables carbon dioxide gas to be delivered intraabdominally thus creating the initial neronium it comes in different lengths like 80 mm which are used for very thin Pati patients while 120 mm for obese
• 02:30 - 03:00 patients when handling the various needle it should be held like a dart at the time of insertion on the other hand the most common access device that we use nowadays is your tro car canula system it refers to the entire assembly but the actual tro car is a stylet which is introduced through the canula this system will only allow insertion of a lap oscope or other instruments through
• 03:00 - 03:30 the canula tro cars have two general categories first is your bladed or cutting tro cars having a sharp metal or plastic blades that cut through the layers of the abdomen as force is applied providing ease of application bladeless or dilating troker on the other hand have tips that bluntly separate and dilate tissues as force is applied pointed or bladed tips are required to
• 03:30 - 04:00 reduce the amount of force required to enter the abdomen and it comes in different shapes the pyramidal chokers are found to cause a greater defect in the abdominal wall compared to the conical tips the conical systems capitalize solely on the sharp tip during placement the force applied relies on the radial dilation of the abdominal wall to allow insertion of the remainder of the canula
• 04:00 - 04:30 therefore stretching abdominal tissues rather than cutting them this results to better troa retention and less trauma to the tissues your blunt tip tro car as opposed to the sharp tip tro cars are at trumatic to the internal viscera they avoid muscle and fascial incision thus decreasing the risk of P site hernas this Strokers can usually accommodate a wide range of instruments and it it is
• 04:30 - 05:00 usually used in the initial AIS using the hasson or open technique which was first described by Dr harit hasson all the canula have a valve mechanism at the top which allows instrument to move in and out within the canula without the loss of numo ponum there are many types of valves which are dependent on amount of gas leakage mode of operation and location on the tro cars examples of
• 05:00 - 05:30 are this is a springloaded or magnetic trapo valve that requires a singleand operation with variable levels of gas leakage second is your manual retractable bubes requiring double hand operation instruments can be damaged during introduction if the valves are not open fully this type of valves offer low levels of gas leakage while the flexible silicone allows instruments of
• 05:30 - 06:00 varying diameters to be inserted through the same port to minimize gas leakage metal canulas are reusable however it must be remembered that the metal sleeves May conduct electrical current to the abdominal wall or visceral organs when in contact with electrocautery so it is important to ensure that the insulation of the laparoscopic instruments is intact at all times
• 06:00 - 06:30 on the other hand plastic canulas are disposable and has a non-reflective surface however under an electron microscope plastic sleeves are quite porous its porosity makes it unsafe for soaking and reusing due to contamination issues it is worth mentioning the optical truers these are bladeless tips that provide Direct visualization of all
• 06:30 - 07:00 layers of the abdomen thereby minimizing size of the skin incision and reducing the force necessary for insertion however these Optical tro cars are nons superior to other tro cars since they do not avoid visceral or vascular injuries minimally invasive surgery requires specialized instruments in performing procedures within the workspace
• 07:00 - 07:30 the laparoscopic hand instruments are generally comprised of three parts first one is your insert second is your shaft third is your handle so the insert or your tip is the working portion of the instrument that defines the instrument's function the inserts or tips are interchangeable and Vary with the specifically designed jaw such as your diss sector grasper sissors or
• 07:30 - 08:00 shears or others the jaw action can be single action or double action single action has only one of the jaw articulating perceived advantages of this design is that the force applied is concentrated to a single articulating jaw this allows the operator to concentrate on activities on the plane occupied by the mobile jaw but the opening of the jaw is narrow ER compared
• 08:00 - 08:30 to the Double Action jaw on the other hand the double action has both Jaws articulating this is the preferred design for dissectors which allows greater tissue separation and access to different planes the shaft is an insulated metal sheet through which the insert runs and connects to the instrument handle this part of the insert comprises most of the length of the
• 08:30 - 09:00 instrument the length is chosen based on the distance to the Target structure for example your adult versus your pediatric patient non-obese versus obese patient or other intraoperative situations the insulation covering is made either of silicon or plastic and serves to minimize or prevent accidental electrosurgical injuries like conductive or direct
• 09:00 - 09:30 coupling the handle controls the insert and have features that contribute to additional functionality of the instrument there are different configuration handles designs that contribute to comfort and ease of use it can be radial aell or an ergonomic handle but it's usually based on the preference of the surgion these are the different parts of the handle this is the rotation KN which provides a means
• 09:30 - 10:00 of rotating the tip 360° and the Coty post which allows for connection to the electrosurgical device to provide either monopolar or bipolar electrosurgical capabilities the ratchet mechanism which allows for locking and unlocking of the Jaws minimizes hand strain when holding tissues for extended periods for the insert it comes in different types
• 10:00 - 10:30 namely the dissectors graspers and scissors dissectors are used for exposing isolating or separating structures from the tissue covering or surrounding it its jaws are usually of the double action type fine tip and either straight or curved jaw here are some examples of a dis sector the most popular dissector is the Maryland dis sector other commonly used ones include
• 10:30 - 11:00 the dolphin and the right angle diss sector graspers are used for manipulation for retraction or for exposure of structures the jaws of this instrument can be of the single or double action type depending on how delicate or robust the target structure is and the desire to work in a single plane the jaws of the graspers are either grouped serrated or toothed to enhance its holding capabilities and
• 11:00 - 11:30 adapted to the Target tissue fine groupes and serration for at trumatic grasping of delicate tissues and penetration of the jaw likewise allows for a firmer hold as the tissue molds into this fenestrations other graspers like the regular tooted and at trumatic scissors and shears inserts are used for cutting sharp dissection and at times even
• 11:30 - 12:00 assist in exposure there are five different types of scissors that you should be familiar with your straight curved serrated hook and micro scissors straight scissors is a straight bladed scissor used for dissection curved scissors slightly curved blade probably the most frequently used scissors preferred by surgeons as the curvature of the blade provides for a better view serrated cissors is wherein the
• 12:00 - 12:30 serration in the edge of the blade minimizes the slippage of tissue or ligature H scissors has the advantage of encircling the structure before cutting ensuring there is no slipage your micro cissors facilitates partial cutting of structures such as of the cystic duck for canulation prior to colang geography or of the common B duck for exploration these are the coagulating or dissecting
• 12:30 - 13:00 electrodes that we use mainly for monopolar cutting and coagulation spatula which has a blond tip while hook which is commonly used can be of L shape or J shape the advantage of this instrument is the delivery of current along a specified point or area your needle drivers and holders are specialized group of hand instruments intended solely for performing
• 13:00 - 13:30 intracorporeal suturing intracorporeal suturing and not tying are challenging skills necessary in Mis the instrument needed for this purpose needs to have the following components first it should have strong Jaws to grip the needles and sutures it should have a sturdy shaft that holds up to the rotational forces being applied it should have an ergonomic handle to to minimize strain
• 13:30 - 14:00 and a reliable and controllable ratchet mechanism the jaws of the needle driver or holder varies it can be straight it can be curved or equipped with a self-aligning mechanism which automatically orients the needle perpendicular to the Jaws notot pushers are usually long metal rods with specially design tip
• 14:00 - 14:30 used to perform extra corporeal knot tying the knots are formed outside of the workspace and brought in throughout the tro car and locked inside using this instruments the choice of tip design is usually based on the surgeon's preference titanium Clips are similar to the one used in open surgery the difference is the clip applier which is longer in laparoscopic surgery while the absorbable Clips or the polymer Locking
• 14:30 - 15:00 liation System is a unique design and has a flexible hinge which keeps the clip firmly seated in applier Jaws the clips comes in different sizes and colors medium being the smallest which can clip structures approximately 7 mm in size like thin ducks and arteries medium large for structures approximately 9 mm like your cystic duck duck or artery her larger structures of
• 15:00 - 15:30 more than 11 mm like her wide cystic duck and large mestic vessels you can use the large or extra large clips whichever is applicable laparoscopic retractors similar to those used in open surgery are meant to provide exposure by moving aside the mass of powel large solid organs like the liver or large viscus like the stomach out of the field of
• 15:30 - 16:00 view similar to hand instruments semal laparoscopic retractor have designs with different features each have its own advantages or disadvantages there are two types namely your static and your Dynamic retractors the natthanon liver retractor is mainly used in upper GI procedures necessitating liver retraction this device is inserted through the epigastric puncture site initially made
• 16:00 - 16:30 by the tro car the device is maneuvered and positioned under the liver and held by an operating table attached bracket this is excellent for long procedures requiring no assistant intervention once set it is however a static retractor made especially for liver retraction while the handheld retractors are Dynamic retractors held by by the assistant which allows for adaptation
• 16:30 - 17:00 and repositioning as the operation progresses there is need to monitor these devices during the course of the procedure as they can cause inadvertent injury examples are the fan retractor and the snake retractor this is your fan retractor which has a retraction head that opens up like a handheld fan when activated the snake retractor is initially a floppy tube that once it is
• 17:00 - 17:30 inserted through the tro car and the tension knob Twisted the tube stiffens and assumes a predetermined configuration fluids in the confined workspace of Mis obscures the work area by blocking direct Vision as well as absorbing the illumination a critical instrument in clearing these fluids is the irrigation and suction device which evacuates the fluid by suction fing and dislodging
• 17:30 - 18:00 adherent debris by flushing with water these devices are usually connected via tubings to the irrigation fluid source and the vacuum suction device with a reservoir to evacuate fluid it also has different activation mechanisms your lever your trumpet or trigger handle designs it also has different tube diameters and tip design like your single or multier ated or combined with
• 18:00 - 18:30 Coty feature are available for the comfort and preference of the surgeon the suction tip has multiple fenestrations to increase suctioning of the fluids the fenestrations lessen the chance for clogging by the surrounding tissues the ball tip suction can simultaneously coagulate tissues and suction fluids this is advantageous in situations where coagulation is needed in areas with bleeding aside from categorization of the
• 18:30 - 19:00 instruments according to their function they can also be grouped as to reusable disposable and reposable reusable instruments are meant to be used multiple times they're mainly constructed of metal Parts designed to be durable and sturdy to withstand sterilization cycles and the wear and tear of repeated use they should also be readily dismantled for cleaning and
• 19:00 - 19:30 maintenance your disposable instruments are meant for single use only they came about in response to perceived High Cost of Labor and maintenance of the reusable instruments disposable instruments are usually manufactured of less costly materials tend to be flexible and wear down easily the term reposable combines the words reusable and disposable this is going to to describe a group of
• 19:30 - 20:00 instruments that are composed of both reusable which are your handles and disposable which are your insert components in which this is a sturdy instrument requiring minimal maintenance at a lower cost your hand instruments can be either insulated or non-insulated generally instruments not meant to have electrosurgical capabilities or non-insulated these are your needle Drive ders notot pushers some irrigation
• 20:00 - 20:30 and suction devices while the shaft of the insulated hand instruments are usually covered by a non-conducting material like your silicone or your plastic insulation prevents conduction of the electrical current into the surrounding tissues and prevents dissipation of heat that cause inadvertent thermal injuries it also limits the electrosurgical feature to the working tip of the in ment this is the end of the first part
• 20:30 - 21:00 of my lecture I hope you will now be able to describe and discuss the proper application of the varied Mis instrumentation and that to understand the basic technology behind each tool as you perform a safe laparoscopic surgery for the laparoscopic Tower you may review my presentation labeled as part two thank you