Equipment detail 1, Equipment detail 2, Equipment detail 3, Equipment detail 4, Equipment detail 5
READ ABOUT LAPAROSCOPIC EQUIPMENT AND INSTRUMENTS
Uterine manipulator
Uterine manipulator is one of the very essential instruments for mobilization of the uterus, identification of the fornices and sealing during hysterectomy. Uterine manipulator is used in most of the advance gynaecological procedures.
Fallop ring applicator is used for application of silastic ring to perform tubeligation. These may be fitted with one or two silastic rings.
Endo-knife (scalpel)
The knife is not used frequently in endoscopic surgery due to the problems associated with the safety of a blade, which cannot be closed or deactivated. However it does have some important uses;
In our practice a disposable blade (Beaver) is mounted on a metal rod, which has a socket at the distal end into which it can be screwed.
The most common use of the knife is for opening the hepatic duct or common bile duct during exploration for stones. A small, clean cut, linear stab wound is created in the anterior wall. Great care is required during incision and removal of the knife. However a sharp curved scissors is better and safer than the endoknife for the choledochotomy.
Biopsy Forceps
Punch, Cutting and Dissecting biopsy forceps are used to take biopsies at the time of laparoscopic surgery. The toothed punch biopsy forceps has special teeth which prevent accidental drop of tissue inside the abdominal cavity.
Coagulating and Dissecting Electrodes
Spatula and hook is the main electrode used for monopolar cutting and coagulation.
Spatula is either "W" shaped or Blunt. Hooks are also of various shapes eg; "L" shaped, "J" shaped or "U" shaped.
Some ball shaped, Barrel shaped or straight coagulation electrodes are also available to achieve proper haemostatis. These blunt electrodes are particularly useful when there is generalized oozing of blood and surgeon can not see specific bleeder point eg; bleeding from the gallbladder bed at the time of laparoscopic cholecystectomy. These blunt electrosurgical instruments are also used for fulguration at the time of ablation of endometriosis.
Bipolar Forceps
Bipolar forceps are one of the very important electrosurgical instruments in minimal access surgery. It is safe compare to monopolar current because electron travels only through the tissue held between the jaw and patient body is not a part of circuit. Both the jaw of bipolar is insulated and the patient return plate is not necessary to be attached. The detail principle of electrosurgery is discussed in chapter of laparoscopic dissection techniques of this book.
Aspiration Needle
These lo needle is used in laparoscopy to aspirate fluid from distended ovarian cysts, gall bladder, or any localized pocket of pus in liver. It may be used for drilling of polycystic ovary. Aspiration needle should be inserted inside the abdominal cavity with extreme precaution because if the pathway of entry or exit is ignored it can cause perforation of viscera.
Fan retractor
These retractors are used to retract Liver, Stomach, Spleen or bowel whenever they interfere in vision or they come in way of other working instrument. There are many newer variety of retractors are available now a days which are less traumatic. Cuschieri liver retractor is one of them which is very useful in Fundoplication.
This liver retractor has a distal end which can be rotated by moving handle. Retractor is introduced in abdominal cavity when it is straight. Once it is inside the abdomen the distal end can take various shapes just like serpent. This retractor can also be used for simple, atraumatic manipulation of bowel.
Needle holders
If surgeon or gynaecologist wants to perform any advance laparoscopic procedure they should develop art of laparoscopic suturing and knotting. Laparoscopic knotting and suturing should be learnt on a good quality endotrainer. The art and science of laparoscopic suturing and knotting is explained in chapter of tissue approximation technique of this book. Surgeon should slowly expertise these techniques. They will develop their confidence once they are capable of suture inside abdominal cavity and there conversion rate will also decrease.
Many automatic laparoscopic suturing devices are invented for intracorporeal suturing but none of them are substitute of manual laparoscopic suturing because these devices can work only under appropriate tissue plane suitable for there application.
Knot Pusher
Although pre-tied loops are available in the market but surgeon should learn how to tie these extracorporeal knot.
Pre-tied loop can be used for any free structure like appendix but for continuous structure like cystic duct surgeon has to perform extracorporeal knotting intra-operatively. For Extracorporeal Knotting knot pushers are used. These knot pushers are of either closed jaw or of open jaw type.
Laparoscopic clip applicator
Titaneum is most widely used metal in minimal access surgery for tissue approximation. It rarely reacts with human body and this is one of the good properties why it is so popular. It is easy to apply and can be left inside abdominal cavity. After few weeks it is covered by fibrous tissue. Titaneum clip is used by 99% of surgeons for clipping cystic duct and cystic artery at the time of laparoscopic cholecystectomy. Recently newer silicon clips has been launched.
The jaw of clip applicator should be at right angle to the structure and before clipping surgeon should take care that both the jaw is seen. If one of the jaws is hidden there is always a possibility that some tissue will get entrapped between the jaw of clip and clip will be loose. At the time of securing any duct or artery with titanium clip, three clips are generally applied. Two clips are left towards the structure which is secured and one clip is towards the tissue which surgeon wants to remove to prevent spillage of fluid. The distance between first and second clip should be 3mm and distance between second and third clip should be 6mm so that after cutting in between second and third clip there will be 3 mm stump both the side. The clip should not be applied very near to each other, because clips are held in position by dumbbell formation and if they are very near to each other they will nullify the dumbbell formation of each other and both the clip will be loose.
Cystic duct clip stone
Recently many cases have been reported of cystic duct clip stone and this is the reason why in many institutions clipping of cystic duct is replaced by extracorporeal knotting. If titanium clip is applied on the cystic duct sometime it may crush one of the walls of cystic duct and it may get internalized inside the lumen of cystic duct. Inside the lumen of cystic duct it acts as a niddus for the deposition of bile pigment and then formation of stone. After cross section of these stone the clip inside is seen glistening like pupil of a cat and so it is also known as "Cat eye stone". These stone can slip inside the CBD and it may cause CBD obstruction. Although the reported case of CBD obstruction is very less the surgeon should try to ligate cystic duct to avoid this complication.
Irrigation and Suction tube
Laparoscopic suction and irrigation tube is one of the very important instruments which surgeon should practice frequently. Vision is one of the limitations of laparoscopic surgery. The blood is the darkest colour inside abdominal cavity and excess of blood inside absorbs most of the light. Whenever there is bleeding inside one should first try to suck it out. Suction irrigation tube also can be used for blunt dissection. At the time of using suction and irrigation the tip of the suction irrigation cannula should be dipped inside blood otherwise the gas will be sucked and surgeon will loss his vision due to loss of pneumoperitoneum. 10 mm suction tube should be used if there is more than 1500ml of hemoperitoneum or if there is blood clots inside the abdominal cavity. Sometime small spilled stones can also be sucked with the help of laparoscopic irrigation suction tube at the time of laparoscopic cholecystectomy.
Fallop ring applicator
Fallop ring applicator is used for application of silastic ring to perform tubeligation. These may be fitted with one or two silastic rings.
Myoma Fixation screw
This is used to fix the sub serous or intramural myoma at the time of laparoscopic myomectomy.
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