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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_197_библиотеки_им_акад_М_И_Перельмана
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Laparoscopy andHysteroscopy Surgery Instruments/Equipment
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Fig. 3 EndoCAMeleon (0°–120°) by Karl Storz
Fig. 4 EndoEYE Flex (100° in four directions) by Olympus
2.2 Laparoscopic Hand
Instruments
These are all the instruments used in performing
laparoscopic surgery. The two varieties of hand
instruments are dismountable and non-
dismountable. The dismountable instruments can
be separated into different parts, namely, the handle, shaft, and working element (the jaw), while
the non-dismountable ones cannot be separated
into different parts (Fig.5). The hand instrument
has a rotator mechanism on the handle to adjust
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the direction of application and a knob for attachment of the diathermy cable to energize the
instrument if required.
The dismountable instruments have better
asepsis, have wider options with minimum extra
costs and are economical to repair. They, however,
are more expensive and have weaker construction
and weaker tactile feedback [2]. The non-dismountable instruments are cheaper and have a
stronger design, longer life span and better tactile
feedback. However, they have limited repair
options and have an increased risk of sepsis due to
tissue materials impacting the joints and crevices
in the instrument. The commonly used hand
instruments in MAS are discussed below.
2.2.1 Dissecting Forceps
They are commonly called “Maryland” and functions like the artery forceps in open surgery
(Fig.6). They are used for tissue dissection and
can be energized for electro-dissection. The
monopolar or bipolar options are available.
2.2.2 Grasping Forceps
These serve as the surgeon’s hands and hence are
indispensable in laparoscopic surgeries. There
are two types:
1. Traumatic. This is toothed (ne or coarse). It
can also be called “Allis”. It is used to handle
thick tissue like fascia, muscle and any other
tissue to be removed from the body. See
Fig.7.
2. Atraumatic. This is non-toothed and could be
fenestrated or non-fenestrated for holding
fragile tissues like fallopian tubes, intestines,
etc. Also, there is a particular design called
Babcock like the one in open surgery.
2.2.3 Scissors
Like in open surgery, the scissors are used for
cutting. There are three commonly available
types. The hook scissors is used for cutting
sutures. The others are the straight scissors and
curved scissors which are used for cutting and
dissecting tissues. During usage, ensure that the
scissors cut from “end to edge”. See Fig.8.
Fig. 5 Laparoscopic hand instruments
Fig. 6 Maryland forceps
2.2.4 Biopsy Forceps
They are specially made for taking tissue specimen (Fig.8).
2.2.5 Suction/Irrigation Cannula
This same instrument serves as a channel for both
irrigation and suction. It has two openings, one
for connection to the irrigation tube and the other
for connection to the suction tube. There is a
knob for switching to the irrigation channel
which automatically turns off the suction channel
and vice versa. It has either reusable suction tips
or disposable suction tips.
The suction function can be used to aspirate
uid including blood from the pelvis, drain ovarian cysts, etc. The irrigation function can be used
for peritoneal lavage, hydro-dissection, and cooling tissues that have been subjected to thermal
energy. See Fig.9.
2.2.6 Energy Delivery Instruments
These are instruments used to deliver energy to
the tissue being operated. The energy used during MAS is usually in the cutting or coagulation
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Fig. 7 Showing Allis traumatic and fenestrated/non-fenestrated atraumatic forceps
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Fig. 8 Laparoscopic scissors—cutting, straight and curved (left) and biopsy forceps (right)
Monopolar instruments include L-hook and
spatula (Fig.10a) and any of the energized hand
instruments. Bipolar forceps include Bissinger, U
design (Fig.10b) and bipolar Maryland.
Tripolar devices combine bipolar coagulation
and monopolar cutting function in one instru-
Fig. 9 Laparoscopic suction irrigation cannula (two way)
ment. It may use electrical or ultrasonic technology. Examples are Harmonics, Covidien, and
waveform. Also, the instruments are designed to
Lotus brands. See Fig.10c.
function as monopolar, bipolar or tripolar technology. As the current passes through the tissue
with high resistance, heat energy is generated
which cuts or coagulates the tissue. Bipolar
instruments are safer than monopolar as the current only has to travel between the prongs of the
electrodes and not through the patient. Many
laparoscopic hand instruments can also be energized to serve as energy delivery instruments.
2.2.7 Hysteroscopic Hand
Instruments and Units
Just like laparoscopy, hysteroscopy makes use
of hand instruments. Because of the narrower
working space in hysteroscopy, these instruments tend to be more slender and longer than
those used in laparoscopy. However, the working tips are similar. Common accessory instru-
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a
b
c
Fig. 10 (a) Monopolar L-hook energy delivery instrument. (b) Bipolar forceps U design and the tip of the instrument.
(c) Harmonic generator and handpiece instrument
Fig. 11 Alligator grasping (left) and biopsy forceps (right)
ments are alligator grasping forceps and biopsy
forceps (Fig. 11) and scissors and tenaculum
(Fig.12).
2.2.8 Hysteroscopy Sheaths
We have diagnostic and operative sheaths which
can be exible or rigid. See Fig.13.
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The hysteroscope has an inner sheath that provides the channel for the telescope and the inow
port for delivery of the distending media. It has
an outer sheath with the outow for the return of
distension media. The diameter of the sheath
depends on the outer diameter of the telescope
and generally has a 1-mm clearance between the
inner wall of the inner sheath and the telescope to
create room for delivery of the distending media.
This is the diagnostic sheath. The operative
sheath is larger and has an extra port for the insertion of the operating instrument. This operating
channel is sealed with a rubber nipple or gasket to
prevent leakage of the distending medium. See
Fig.14.
Fig. 12 Scissors (left) and tenaculum (right)
2.2.9 Resectoscopes
Resectoscope is a specialized electrosurgical
endoscope (monopolar or bipolar) that consists
of an inner sheath and outer sheath like the hysteroscopy sheaths (Fig.15). The outer sheath is
for uid return, while the inner sheath has a common channel for the telescope, uid medium and
electrode. It has a double-armed electrode tted
to a trigger device that pushes the electrode out
beyond the sheath and then pulls it back within
the sheath. The operating tool consists of four
basic electrodes: a cutting loop, ball, button and
angulated needle (Fig.16). Traditionally, resectoscopes are monopolar instruments, but bipolar
resectoscopes are gradually replacing them for
reasons of safety [1].
Most resectoscopes have a 30°telescope.
The lens is angled toward the electrode to permit a clear view of the near operative eld. It
can be used with monopolar or bipolar circuit.
When using monopolar mode, a non-electrolyte
medium like glycine, sorbitol and mannitol is
used and the patient return plate is applied. For
bipolar mode, electrolyte medium like normal saline or non-electrolyte medium can be
used. It has its special generator and a patient
return plate is not required. The biggest advantage of bipolar is that the risk of hyponatraemia is obviated. Glycine causes hyponatraemia
which can cause cerebral oedema and death
Fig. 13 Rigid diagnostic and operative sheaths (left) and exible hysteroscope (right)
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Fig. 14 Hysteroscope with operating channel
J. I. Ikechebelu et al.
[2]. Resectoscopes are useful in a submucous
myomectomy, polypectomy, intrauterine adhesiolysis, endometrial resection/ablation and
metroplasty.
2.2.10 Media Delivery Systems
They are used to deliver the distending medium
into the uterine cavity. The media delivery system can be manually operated or automated.
The pressure bag is manually operated and
allows for intermittent uid delivery leading to
interruptions during the procedure. This system can sufce for diagnostic purposes.
Hystero-pump is automated and ensures continuous uid delivery at controlled pressure
(Fig.17). It is recommended for all procedures
(especially operative) where interruptions may
be detrimental.
Fig. 15 Resectoscope with the different components
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a
b
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Fig. 16 (a) Resectoscope with cutting loop (monopolar left and bipolar right). (b) Resectoscope electrodes (knife, ball,
angle needle and cutting loop in action)
Fig. 17 Automated uid delivery system
3 Instruments forSpecial
3.2 Uterine Cannula
Applications inGynaecology
This is used to inject dye into the uterus during
3.1 Uterine Manipulator
They are used to elevate and change the position
and degree of the version of the uterus during surgeries. They come in different congurations and
sizes (Fig.18).
dye tests. They can also improvise for uterine
manipulation but the degree of manipulation is
limited. The Sparkman cannula (Fig.19) is preferred because it can be anchored to the tenaculum, unlike the Leech-Wilkinson variety.
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3.3 Tissue Morcellators
Sometimes during laparoscopic procedures, the
tissue excised may be bigger than the size of the
incision made and the retrieval of the tissue
becomes a challenge. Rather than making a large
Fig. 18 Mechanical uterine manipulator
incision for the sole aim of retrieving the tissue,
the laparoscopic tissue morcellator (see Fig.20a)
is used to slice the excised tissue into strands/bits
that can be retrieved through port sites.
There are also hysteroscopic morcellators.
Examples are the TruClear hysteroscopic morcellator and the MyoSure tissue remover. Hysteroscopic
morcellators are used for hysteroscopic polypectomy and myomectomy. See Fig.20b.
3.4 Monopolar Drill
It is a monopolar instrument that is used for laparoscopic ovarian drilling in polycystic ovaries.
See Fig.21.
Fig. 19 Sparkman uterine cannula
Fig. 21 Monopolar drill
b
Fig. 20 (a) Laparoscopic morcellator. (b) Hysteroscopic morcellator
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Fig. 22 Probe, myoma screw and striper
Fig. 23 The needle driver/holder (straight, toothed and curved jaws)
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3.5 Probes
Blunt probe is used for movement, displacement,
stabilization and manipulation of mobile tissues
(e.g. intestines and ovaries) during endoscopic
procedure. See Fig.22.
3.6 Myoma Screw andStriper
It is used in myomectomy for enucleation of uterine myomas (particularly the intramural types).
See Fig.22.
4 Instruments forTissue
Approximation
andHaemostasis
These include instruments used for suturing and
for application of clips and staples.
A. The needle driver/holder is used for suturing. The jaws could be straight, curved or toothed
in some designs to include grasping function
(Fig.23). The handle may be straight or curved.
The straight handle is considered to be ergonomically more suitable for suturing in varying
situations.
B. The clip applicator is used to put the clips
in place (Fig.24). A sturdy clip applicator is preferred as the process of applying clips uses a lot
of force. The clips come in three sizes– small,
medium and large. The clip applicator similarly
has detachable tips of different sizes to match the
small, medium and large clip sizes.
C. Laparoscopic staplers are used for the
application of surgical staples. The Endo GIA
laparoscopic stapler is designed for gastrointestinal anastomosis but can be used in gynaecologic
laparoscopy as a stapling device for securing haemostasis and dividing tissue (Dutta, 2013) [3].
After placing and ring the preloaded device, six
staggered rows of staples, 3 cm in length and
1 cm in width, are left behind. A knife blade
simultaneously divides the tissue, leaving three
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rows of staples on each side of the incision. See
Fig.25.
D. Harmonic makes use of ultrasound energy
source, and hence, there is no risk of electrical
injury. It is used in cutting or coagulation of tissues. It is effective in sealing of vessels up to
4mm in diameter. See Fig.10c.
E. LigaSure: It is used to cut, vaporize,
coagulate and seal blood vessels. LigaSure
works on bipolar technology. It is less likely to
cause lateral thermal spread, sticking and charring of tissues. It seals blood vessels, up to
7mm in size.
Fig. 24 Clip applicator
5 Instruments forAccess
5.1 Veress Needle
It is used to insufate the abdomen with gas so as
to create pneumoperitoneum (Fig.26). It is available in reusable and disposable models. It contains a spring-loaded tip that retracts as it pierces
the abdominal wall, allowing a blunt tip to engage
on entry to the peritoneal cavity. The spring system helps to avoid injury to the bowel, intraabdominal organs and major blood vessels [3].
5.2 Trocar andCannula/Sleeve
They are used to pierce the abdominal wall and
create a conduit for the placement of the laparoscope and hand instruments (Figs. 27 and 28).
The cannula bears the trocar. After piercing the
abdominal wall, the trocar is removed and the
telescope or hand instrument is introduced
through the cannula (sleeve). The trocar/cannula
ranges from 3 to 15 mm in diameter so as to
accommodate the various sizes of telescopes and
instruments. Trocar and cannula are available as
reusable, disposable and reposable systems.
Fig. 25 Laparoscopic stapler
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