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WHAT TOOLS ARE USED IN LAPAROSCOPIC SURGERY?

Laparoscopic instruments are made of durable materials and usually high quality stainless steel. Instruments all have a very narrow shaft so that they can fit inside laparoscopic ports. Sizes typically range from 3 mm, 5 mm and 10 mm sizes. A variety of tips are available for manipulating the tissue and handle styles may allow ergonomic rotating, grasping and locking abilities in a precise fashion.


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.


LAPAROSCOPE


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.


NEEDLE DRIVER


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, including disposable laparoscopic instruments and reusable laparoscopic instruments, is classified as straight or curved depending upon the shape of the jaws.


TROCAR


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.


BOWEL GRASPER


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.


SURGICAL MESH


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.1 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.


Disposable or reusable?


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.


Uterine manipulators


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 accessories and procedures.


Veress needle


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 with ultrasonic system. 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.3


Trocars/cannulas


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:


Sharp tips cut an entry path through the abdominal wall while blunt tips stretch the tissues apart to gain access to the peritoneal cavity.


Sleeve: is the working channel. Trocar sleeves or collars can have textures on the outer surface of the trocar that help it anchor to the abdominal wall. Some have an internal inflatable balloon at their tip and plastic/rubber ring to provide anchorage.


Valve: different valve systems prevent gas leaking from trocars and allow the insertion of instruments.


Side port: many trocars come with a side port that allows for gas insufflation or smoke evacuation.


Laparoscopes


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.

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