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Hand Instruments Handbook of Laparoscopy Instruments 59
https://t.me/medicina_free
Graspers
Dissection and grasping instruments: Dissect means “methodically cut up (a body
or plant) to study its internal parts”. Dissection is probably the finest part of the
surgery. Almost all standard instruments available for laparotomy are available in
a specialized form to fit through an endoscopic 3–20 mm port. Grasping forceps
have been designed for tissue manipulation and may be locking (ratcheted) and no
locking (non-ratcheted). Some forceps are broad and flat, while others are finer
and made for delicate tissue handling.
Atraumatic stabilization of structures is achieved by fine grasping forceps
multiseriate and with a round tip. With atraumatic forceps, the surgeon can expose
and perform the counter traction needed to dissect and make a suture, for
example, prehension of the Fallopian tube or the ureter. A Babcock-type
atraumatic grasper with a ratcheted scissors handle can be particularly useful in
handling mesentery or adnexal structures. Toothed (claw forceps) are used to
grasp and liberate solid organs. In a laparoscopic cyst extirpation, to fix the ovary
properly and remove the cystic capsule, it is crucial to use strong grasping
forceps. Forceps with pointed ends are used for tissue dissection and surgical
plane development. Dissecting and grasping instruments are available in either
reusable or disposable forms. The disposable instruments are typically less costeffective, although they have the advantage of being available (when properly
stocked), and the cutting edges are always sharp.
In contrast, no disposable instruments may be in the process of cleaning and
resterilization, mainly where many laparoscopic surgeries are performed. Most
dissectors and graspers have the availability of electrosurgery connection.
Graspers are used to grasp or hold the bowel and intra-abdominal viscera during
operations. Graspers may be traumatic or atraumatic. Large grasping instruments
are used to attain the proper retraction.
Traumatic Grasping Forceps
They are used to hold the tissue firmly. They hold the tissue firmly without
slipping it for a long time if the ratchet is closed but causes trauma to tissues.
Atraumatic Grasping Forceps
These are used to hold the tissue without causing trauma to it. These are mainly
used to have an appendix, bowel, etc.
60 Handbook of Laparoscopy Instruments Nagtode et al.
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Bullet Nose Grasper
These graspers have an atraumatic grasping jaw (which causes minimal tissue
damage) with a blunt bullet nose design to its tip Fig. 7.3. They contain serrations
which may be diamond cut or straight. These graspers are considered perfect for
grasping and dissecting the structures comprising fine and fragile anatomy.
Fig. (7.3). Bullet Nose Grasper with atraumatic grasping jaw.
Washing of the serrations of the jaw and hinged areas of the instrument have a
pivotal role which requires greater recognition.
Dorsey Intestinal Fenestrated Grasper
Fig. (7.4) has atraumatic horizontal serrations.
Fig. (7.4). Dorsey's intestinal fenestrated grasper with atraumatic horizontal serrations.
Hand Instruments Handbook of Laparoscopy Instruments 61
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Hunter Bowel Grasper
Fig. (7.5) has two rows of atraumatic serrations. The jaw comes in different
lengths, depending on the needs of the surgical procedure.
Fig. (7.5). Hunter bowel grasper.
Crocodile Grasper
Fig. (7.6) has long contoured jaws with tissue herniation channels to ensure
superior grasping ability.
Fig. (7.6) shows Crocodile Grasper.
Fig. (7.6). Crocodile grasper.
62 Handbook of Laparoscopy Instruments Nagtode et al.
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Raptor Grasper
See Fig. (7.7) has long contoured jaws.
Fig. (7.7). Raptor grasper with long contoured jaws.
It also has two atraumatic teeth at the tip for grasping complex anatomy. Fig.
(7.7).
Triangular Endo Flex Retractor
Fig. (7.8) (angled or straight) is used for retraction during large organ surgery.
Two standard lengths are 60mm and 80mm.
Fig. (7.8). The triangular endo flex retractor used for the retraction of organs.
Hand Instruments Handbook of Laparoscopy Instruments 63
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Dissectors
Maryland Dissector
Fig. (7.9) has long, curved jaws with fine-tapered tips. Ideal for precise dissection
(resembles the Crile haemostatic clamp used in open surgeries).
Fig. (7.9). Maryland dissector for precise dissection.
Bipolar Dissector Fig. (7.10)
It is made up of four pieces which can be disassembled. While sterilizing the
instrument, it should always be disassembled. It should be assembled after that by
the personnel with scrubs in the sterile field only, following which it is connected
to the bipolar cord. To attain haemostasis is its prime function.
Fig. (7.10). Bipolar dissector.
64 Handbook of Laparoscopy Instruments Nagtode et al.
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Laparoscopic hand instruments are designed for sharp and blunt dissection. Most
instruments are held in palm grip hand position with the pistol handle, i.e.. thumb
outside the ring with the palm resting on the thumb ring.
Instruments for Sharp Dissection
Scissors
These instruments may be straight, curved or hooked. Delicate dissection can be
carried out with straight scissors. Curved scissors, in general, have the same
features as straight scissors. In some cases, they are easier to dissect because the
curvature changes the viewing angle. Hook scissors are particularly suitable for
transecting ligature fibers and tissue transecting (Figs 7.11a and b). It should be
used with great caution while entering and exiting. Scissors can be used for
adhesiolysis, a section of coagulated tissue and sutures cutting. Some have an
electrical adapter, so they can be combined with unipolar or bipolar
electrocoagulation scissors, electrosurgery hooks, and spatula are used for sharp
dissection. Blunting of the scissors can be seen at the sharp edge on multiple and
repeated usage of diathermy. An electrocautery knife can also be used for sharp
dissection.
Fig. (7.11 a). Curved types of scissors.
Fig. (7.11 b). Straight hook scissors.
Hand Instruments Handbook of Laparoscopy Instruments 65
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Bowel and Lung Clamp
Tubular structures, bowel, and lung can be held with instruments designed
specifically for the same (Endo-Babcocks, Endo-Lung, Bowel Clamp) Fig. (7.12a
and b). [3 - 5].
Fig. (7.12 b) Shows the Endo-Lung clamp used for holding.
Fig. (7.12 a). Endo-Babcocksused for holding tubular structures.
Fig. (7.12 b). Endo-Lung clamp.
Needle Holders
Laparoscopic needle holders are available with straight or curved tips. Endosuturing is done with a needle holder and a grasper. The Fig below shows 5 mm,
needle holders. These instruments are essential to perform sutures and knots.
There are different types of needle holders. They may have a straight or curved
handle and straight and curved tips. The co-axial types with a locking system are
66 Handbook of Laparoscopy Instruments Nagtode et al.
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preferred to the pistol-type needle holders (Figs. 7.13a and b). There are also
automatic needle holders that put the needle at a 90º angle after being charged. In
extracorporeal sutures, the aim is to apply tension in a controlled way
(myomectomies, promontofixation, vaginal cuff closure); a knot pusher is
needful.
Fig. (7.13). a) and b) The needle holder.
Coagulation Instruments
Most devices used for coagulation during operative laparoscopy are adapted from
open surgery. More details about electrosurgery were described in the chapter
“Principals and use of electrosurgery in laparoscopy”. Concerning monopolar
instruments, there are different tips available. There is a monopolar highfrequency needle that can be retracted into the sheath. Also, a vast armamentarium
of bipolar forceps with various tips is seen with a coagulating probe.
Hook and Spatula
The hook has an L-shaped tip. Primarily, it is used to dissect the gallbladder from
the bed of the liver. The spatula has the same function as a hook but has a flat tip
for dissecting the gallbladder from the liver bed [6]. It is safer than the hook.
Monopolar hand instruments (Figs 7.14 a and b) also can be used for dissection
and coagulation.
Hand Instruments Handbook of Laparoscopy Instruments 67
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Fig. (7.14 a). Monopolar instruments- hooks and spatula.
Fig. (7.14 b). New generation bipolar forceps and scissors.
Suture Passer Devices
Various types of sutures passers are available for the closure of ports and
transracial ligature Figs. (7.15 a and b). The thread passer has a side slit to carry
68 Handbook of Laparoscopy Instruments Nagtode et al.
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the thread into the peritoneal cavity on one side of the trocar. Once the thread is in
the peritoneal cavity, the instrument is introduced on the other fascia side, and the
thread is pulled out, closing the fascia defect caused, for example, by the trocar
insertion. This procedure should be performed under laparoscopic view and
guidance.
Fig. (7.15). a) and b) suture passer devices.
Vaginal Probe
Fig. (7.16): It is handy for exposing the vagina during deep endometriosis and
prolapse surgeries. Myomas holder: It is difficult to stabilize a smooth, hard
fibroid during a laparoscopic myomectomy. Myoma screws (5 mm and 10 mm)
allow the surgeon to manoeuvre the myoma and apply traction with improved
exposition and access. In the case of a giant myoma, it is better to use the 10 mm
myoma screw. Another alternative for myoma fixation is the use of a strong
tenaculum, offering you more mobility in the myoma traction points.
Fig. (7.16). The vaginal probe.
Irrigation-suction
Figs. (7.17 a-c): During diagnostic and surgical laparoscopy, it is commonly
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