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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_938_Библиотеки_им_академика_М_И_Перельмана
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2 Fundamentals ofOperating Room Setup andSurgical Instrumentation
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Fig. 2.9 Left to right, different varieties of handheld
retractors. (a) Harrington or Sweetheart retractor, (b)
Deaver, (c) Kelly retractor, (d) Eastman, (e) Richardson
retractor, (f) Richardson-Eastman retractor, (g) S-retractor,
(h) Cushing vein retractor, (i) Senn retractor, (j) Rake
retractor, (k) Army-Navy
b
c d
a
Fig. 2.10 Left to right, (a and b) Balfour self-retraining retractor, (c) Weitlaner self-retaining retractor, (d) Gelpi
the task at hand. They can be handheld or self-
Suction (Fig.2.11)
retaining retractors. An example of commonly utilized handheld retractors that are utilized in general
surgery include the Army-Navy and Richardson
retractors. Similarly, self-retaining retractors, such
as the Bookwalter and Balfour, are commonly utilized during large abdominal procedures. There
are also smaller self-retaining retractors, such as
the Weitlaner, which are used during open procedures, such as an inguinal hernia repair.
Visualization of the operative eld is important,
which is accomplished through the use of suction
devices. Sizes of the suction tip depend on the
area and type of tissue being worked on. The
commonly used Yankauer aspirates through the
tip end and is either disposable plastic or reusable
metal. A Poole sucker has multiple ports all along
the side and is used to quickly aspirate a large
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Fig. 2.11 Left to right, (a) Yankauer suction; (b) Andrews suction; (c) Poole suction; (d) Frazier suction; (e) Poole
suction broken down into its components
volume of uid, such as after irrigating the
abdominal cavity with liters of saline. Smaller
tips include the Andrews or Frazier, usually used
in pediatric or vascular cases. Suction on Frazier
tips are controlled by a small hole on the handle.
areas, and with or without teeth depending on the
power of the grip desired. Tissue type and desired
outcome are some of the factors that determine
clamp choice. Babcocks are used to grasp bowel
rmly while causing the least amount of damage,
whereas a Kocher has multiple serrations that
allow for strong grasping of fascia.
Clamps (Figs.2.12, 2.13, 2.14, 2.15, 2.16,
and2.17)
Basics ofInstrumentation
Clamps are used to hold objects in place and/or to
maintain control of tissue, such as cutting off
blood ow to an area of interest. They can be
either straight or curved, perforating or nonperforating, ne-tipped for more precise clamping or broad for thicker or more generalized
andEquipment forLaparoscopic
Surgery
Laparoscopic procedures require surgical skills
that include dexterity, efciency, and the ability
to operate in a three-dimensional environment
2 Fundamentals ofOperating Room Setup andSurgical Instrumentation
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Fig. 2.12 Left to right, (a) curved Crile; (b) straight Crile; (c) mosquito
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ab c
Fig. 2.13 (a and c) Perforating towel clip; (b and d) non-perforating towel clip
d
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d
Fig. 2.14 (a and c) Straight Kelly clamp; (b and d) curved Kelly clamp
c
Fig. 2.15 (a) Kocher
clamp; (b and c) Kocher
clamp details
ab
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Fig. 2.16 (a) Right angle, two different sizes; (b) right angle details
ab c
d
Fig. 2.17 Left to right, (a and c) Allis clamp; (b and d) Babcock clamp
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d
e
Fig. 2.18 Laparoscopic tower that includes the necessary
hardware during a laparoscopic case. (a) Broad overview
of components located on the tower. (b) Insufator measures the pressure and the ow of gas that is provided dur-
ing the case. The surgeon can vary the insufation pressure
by adjusting the preset pressure. (c) Transmitter that allows
for signal to be sent to other monitors in the room. (d)
Camera connection. (e) Light source connection
that is usually visualized in two dimensions. In
Imaging System
addition to patient and surgeon positioning, one
must be cognizant of equipment positioning in
order to facilitate the expeditious progression of
the operation. The equipment that is required to
carry out a laparoscopic case, such as the components of the imaging system or insufator, is
oftentimes located on a laparoscopic tower
(Fig. 2.18). For the remainder of this section,
basic laparoscopic equipment and the fundamentals of proper use will be discussed. A more
detailed overview of instruments used in laparoscopic surgery can be found in the appendix of
this book.
The imaging system consists of the laparoscope,
camera, video monitor(s), and light source. In gen-
eral, the sterile components of this system include
the laparoscope, camera, and ber-optic cord that
connects the laparoscope to the light source.
Most modern laparoscopes utilize a rod-lens
system that was initially discovered by Harold
H. Hopkins in the late 1950s. This was coupled
with ber-optic transmission technology by Karl
Storz in the 1960s. Since then, the rod-lens system
has revolutionized laparoscopy [5, 6]. Signicant
advances have been made that allow for a number
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of laparoscope options, and therefore, not surprisingly, laparoscope selection is largely surgeon
dependent. The ultimate goal when selecting a
laparoscope is to maintain adequate visualization
of the operative eld. Laparoscopes can vary in a
number of ways, as described below.
•
Size—The diameter (or size) of the laparo-
scope can vary from 0.88mm to 12mm. The
larger the diameter of the laparoscope, the better the visualization. The most commonly utilized laparoscopes are 5mm and 10mm.
Angle—The angle of laparoscope can vary
•
from 0 to 70°. A laparoscope that is 0° allows
for a panoramic view, i.e., provides a view of
the eld that is directly ahead. In contrast, an
angled laparoscope allows one to view a structure from different viewpoints without the
necessity to change between ports. The most
commonly utilized angles are 30° and 45°. An
important tip to remember when using an
angled laparoscope is to point the angle away
and not toward the area of interest [7].
Signicant advances in camera designs have
occurred as laparoscopy has become more popular.
Perhaps the most notable advance in enhanced
imaging in laparoscopy has been the introduction
of the charged-coupled device (CCD) chip camera
and digital video imaging (i.e., high- denition
imaging). In the future, improvements in threedimensional imaging will address depth perception,
which is lost with two-dimensional imaging. There
are a number of features and controls that one must
be familiar when it comes to the laparoscopic camera. Controls present on the camera are manufacturer specic but, in general, include:
•
White balance allows for the color that is pro-
duced by the camera to be adjusted to the
color of the light source. It is important to
white balance the camera against a white
object, such as a lap sponge, prior to use.
• Focus allows for a clear image to be viewed.
Prior to inserting the camera into the abdominal cavity, the camera is held 5cm away from
a target object, and the camera is focused to
the clearest image.
•
Illumination adjustments allow for the inten-
sity of the light to be increased or decreased.
• Optical zoom allows for closer viewing of the
operative eld without loss of resolution of
the image.
Monitors come in a variety of sizes and reso-
lutions. Using a high-resolution monitor with a
camera with similar capabilities optimizes the
quality of the image.
The light source can vary by type and voltage.
The current industry standard is a Xenon lamp
with an output of 300W.The laparoscope is connected to the light source through a ber-optic
cable. Any breakage in the ber-optic cable
results in decreased light transfer from the light
source to the laparoscope, which results in
decreased light being transferred to the operative
eld. Always be mindful of the ber-optic cable
once the illumination is turned on, regardless of
whether or not it is connected to the laparoscope.
It generates a signicant amount of heat that has
been known to start res or burn holes through
the sterile drapes and can lead to patient injury.
Other necessary equipment for laparoscopic
surgery includes:
Insufator—The insufator is necessary to
•
obtain pneumoperitoneum that allows for a
successful laparoscopic case to be carried out.
Several options are available for the type of
gas used to insufate, the most common being
carbon dioxide. Carbon dioxide is preferentially used since it is nonammable, colorless,
and odorless. And, in general, it is safely
absorbed and excreted. Insufator tubing connects the insufator to the instrument (i.e., trocar or Veress needle) that will facilitate the
delivery of the gas into the abdominal cavity.
•
Trocars or ports are used to pierce the abdomi-
nal wall and serve as a conduit that allows for
the entry of laparoscopic instruments into the
abdominal cavity. They can vary in size and be
either cutting or blunt. Trocars can have
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additional features, such as a side port, which
allows for pneumoperitoneum to be maintained if the insufator tubing is changed
between ports [7].
Instrumentation forObtaining Access
totheAbdominal Cavity
When initially planning the location for initial
access for an abdominal laparoscopic procedure,
rst, survey the abdomen for scars from prior surgery or for any masses. Second, keep the planned
operation and the operative eld in mind. The
most common site for initial entry and trocar
placement is the umbilicus. The amount of soft
tissue between the skin and the fascia is less compared to other areas in the abdomen in this location. It is also possible to hide a scar in an existing
skin crease for improved cosmesis. Another common entry location is in the left upper quadrant in
a location known as Palmer’s point, which is
located 3cm below the left subcostal border in
the midclavicular line [8]. Instruments commonly used to obtain access for laparoscopic surgery will be briey described next. For more
specic details, refer to Chap. 14—Fundamentals
of Laparoscopic Surgery.
First described by Dr. Harrith M.Hasson in the
1970s, the open technique for laparoscopic access
is preferred by some as it is believed to minimize
complications such as gas embolism, major vessel
or visceral injury, or insufation of the preperitoneal space [9]. The cannula itself is usually tted
with a cone-shaped sleeve and an outer secondary
sleeve that allows for stay sutures to be placed to
secure the port. It is primed with a blunt obturator
to prevent injury to underlying structures. The
Hasson cannula is inserted into the abdomen with
the blunt obturator in place, and stay sutures
secure the cannula to the fascia on either side to
seal the opening in the abdominal wall and to prevent gas leak during the procedure [10].
The Veress is used to obtain access to the
abdominal cavity during laparoscopic surgery
with the closed technique. The Veress needle was
rst discovered in the 1930s by Janos Veres, and
it was Raoul Palmer who introduced the use of
the Veress needle in laparoscopic surgery to
establish pneumoperitoneum in the 1940s [
It is a spring-loaded needle that is 12–15cm long
with an external diameter of 2mm. It consists of
a two-cannula system. The outer cannula has a
beveled needle that is sharp to cut through the
abdominal wall. The inner cannula is nested
within the outer cannula and has a spring-loaded
stylet with a dull tip. When the Veress needle is
passed through tissue, direct pressure on the tip
of the needle pushes the dull stylet into the outer
cannula. Once the needle tip enters a space, such
as the peritoneal cavity, the dull inner stylet
springs forward and protects any underlying
tissue.
Optical trocars are a relatively new technique
that utilizes the conventional trocar and cannula
push-through design. These units are designed in
such a way that the trocar is hollow and allows
for a 0° laparoscope to be inserted and locked
along with the trocar. It can then be used to visualize entry into the abdominal cavity as the trocar
pierces sequential abdominal wall layers. This
system is generally used after the abdominal cavity has been insufated [
10, 12].
8, 11].
Tips for“Driving” theCamera During
Laparoscopic Surgery
All of the components of the imaging system are
put together to allow the visualization of an
image. Once access to the abdominal cavity is
obtained, proper use of the imaging equipment to
provide adequate visualization during the operation is of paramount importance. Here are a few
pearls for proper handling of the camera and
laparoscope and for effective “driving” of the
camera:
• Practice holding the camera. In general, the
non-dominant hand should cradle the camera
and laparoscope. The buttons of the camera
should always point up.
• The light cord is attached to the laparoscope,
and in the neutral position, it points up. This is
especially important to remember when using
an angled laparoscope, since the direction of
the light cord corresponds to the direction of
the viewing angle.
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• When “driving” the camera, a good rule to
keep in mind is the rule of opposites. To view
an image to the right, the camera is moved to
the left. Or to view an image that is up, the
camera is pointed down. Moreover, the camera should be moved toward the object of
interest to provide a closer view. Movement of
the camera out (or into the trocar) will result in
the ability to get a panoramic view of the eld.
• When using an angled laparoscope, movement of the light handle results in a change of
the angle. Therefore, when the light handle is
in the neutral position, i.e., pointing up, the
viewing angle is down. When the light handle
points up, the viewing angle points down.
• The lens can fog once the laparoscope is
inserted into the abdominal cavity. This occurs
due to the temperature difference between the
outside environment and the intra-abdominal
cavity. This can be avoided by warming the
lens tip in warm water or with the use of antifog solutions [12].
Basics ofInstrumentation
andEquipment forEndoscopy
bilities. The blue button has two features: covering the port will insufate air, while pushing the
button infuses water. Pushing the red button provides suction. A biopsy port allows for the passage of biopsy forceps or other instruments
through the insertion shaft. Camera buttons allow
the operator to obtain pictures or videos.
The insertion tube is a exible cord that is
manually manipulated by the operator by pushing, pulling, and torqueing. The deectable tip at
the distal end of the cord has the capability of exing side to side and up and down via controls on
the handpiece. The tip also contains the port sites
for multiple applications, including a water nozzle for irrigation, an air nozzle for insufation, a
suction channel, a light source, and objective lens.
The umbilical cord is a exible tube that contains all of the channels (air/water, suction, and
light source) that connect to the tower that houses
the video processor and displays screen. The
proximal end of this cord is directly inserted to
the tower. A video processor cord connects the
umbilical cord to the image processor. A water
bottle and suction tubing are connected to the
umbilical cord to allow for irrigation and
aspiration.
Endoscopy in general surgery has many applications and can be used in abdominal or thoracic
procedures. This section will provide a brief
overview of the common components of endoscopes used for upper and lower endoscopy.
The Endoscope
The endoscope is comprised of three main parts:
The handpiece is used to control the direction
the tip of the insertion tube is facing, which aids
in visualization as well as maneuvering the scope
as it traverses a lumen. A large and small wheel is
used to either maneuver the tip up-down or leftright, respectively. Turning of the wheel leads to
tip angulation in the opposite direction on the
monitor. For example, turning the large wheel up
causes the endoscopic tip to be directed downward and vice versa. The wheels can be locked in
a desired position to aid in diagnostic or therapeutic maneuvers, such as obtaining a biopsy.
Buttons on the handpiece control different capa-
The Endoscopy Tower
The endoscopy tower consists of an image processor and display screen, a light source and air
insufator, water irrigation, and energy source.
Once all equipment is positioned and connected
appropriately, check that the insufation, irrigation, and suction are working properly before
beginning the procedure [13].
OR Instruments Used
inLaparoscopic Surgery
Laparoscopes (Fig.2.19)
Laparoscopes come in many varieties, as discussed in the Fundamentals of operating room
setup and surgical instrumentation chapter.
Illustrated here are 10mm laparoscopes, both at
various angles.
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Fig. 2.19 Top to bottom, (a and c) 0° laparoscope, (b and d) 30° laparoscope
Fig. 2.20 Top to
bottom, laparoscopic
graspers; (a) bowel
grasper; (b) Clinch
grasper; (c) Maryland
dissector
a
b
d
c
Laparoscopic Graspers (Figs.2.20
and2.21)
a
Most laparoscopic instruments have a 360° rotating knob to turn the tip of the instrument in order
b
to maintain the wrist in the most ergonomically
neutral position. Electrocautery sources can be
plugged into the metal port on the handle, which
are usually controlled via a foot pedal. The atrau-
c
matic bowel grasper is used to handle more delicate tissue, such as when running the bowel. One
should use the majority of the jaw to grasp the
anti-mesenteric side to minimize damage. Using
just the tip of the grasper can cause more damage
secondary to the increased pressure exerted by the
smaller surface area. A hand-to- hand or hand-
Fig. 2.21 Top to bottom, (a) Cinch grasper; (b) atrau-
matic bowel grasper; (c) Maryland dissector
over-hand technique can be utilized to accomplish
this task. Clinch graspers are usually toothed and
ratcheted, with a locking mechanism. This could
be used to grasp and retract thicker or heavier tissue, such as omentum. The Maryland dissector
that has a pointed tip can be utilized to dissect
through more ne tissues and is commonly used
when dissecting around the cystic duct and artery
during a laparoscopic cholecystectomy.
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