Instruments used in laparoscopy

1. BASIC INSTRUMENTS OF ENDOSCOPY
&
ITS LIMITATIONS

2. Dr. Niranjan Chavan
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson FOGSI Oncology and TT Committee (2012-2014)
Member, Managing Committee, IAGE
Librarian, MOGS (2016-2017)
Chair and Convener, FOGSI Cell-Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Course Co-coordinator of MUHS recognized BIMIE at LTMGH
Member, Oncology Committee AOFOG

3. VERESS NEEDLE
• Available both in disposable and reusable form
• Used for creating initial pneumoperitoneum
• Has two component : an outer hollow needle with sharp
bevelled edge and a blunt, spring loaded inner obturator
with the stop position beyond tip of the hollow needle.
• Available in 3 lengths : 80mm, 100mm and 120 mm

4. VERESS NEEDLE
• Umbilical area is preferred for inserting
veress needle, as subcutaneous area is
reduced here.
• A transverse incision is taken before
inserting the veress needle.
• It is advisable to lift the abdomen to move
the large vessels away.
• Needle passes through the wall and fascia,
there is ‘Popping’ sensation

5. VERESS NEEDLE
• Safety tests for veress needle :
Irrigation and aspiration test
Hanging drop test
Gas insufflation test
• Alternative site for veress needle insertion
are : left upper quadrant, left iliac fossa and
the posterior pouch of Douglas

6. LIMITATIONS OF VERESS NEEDLE
• It can go in the abdominal wall
• Subcutaneous emphysema can go up to the
neck if not detected early
• Can cause injury if the angulation of the entry
point is misdirected leading to injury to
internal organs viz.
• Bladder if not emptied , Uterus
• Bowel perforation, if appropriate bowel
preparation is not done.
• Vessel injury like aorta, mesenteric vessels

7. TROCAR
1 . Trocar with pyramidal tip
2 . Trocar with conical tip
3 . Trocar with blunt tip
• Trocar permit access to peritoneal cavity.
• It can be inserted primarily or after
creating a pneumoperitoneum of
15mmHg through veress needle.
• Trocars are available in various design :
with pyramidal tip, conical tip or blunt tip.

8. TROCAR
• Ideal way to hold a trocar : proximal end
resting on Thenar prominence, with thumb on
one side and rest of the four fingers on the
other side with middle finger on gas inlet and
index finger pointing towards the sharp end.
• Axis of insertion : cranio – caudal direction
• Angle of inclination : 45 degrees to
perpendicular axis and slight trendlenberg
position of the patient.

9. TROCAR
• An alternative method is Visually
Controlled Entry .
• It involves use of a reusable 11mm
cannula with a 0 degree endoscope,
which provides direct visualisation of
the entry tract.
• Ternamian EndoTIP, Visiport, Optiview

10. LIMITATIONS OF TROCAR
• False passage
• Subcutaneous emphysema
• Injury to internal organs wiz
Bladder if not emptied , Bowel ,
Uterus , Ovary etc.
• Vessel Injury viz Aorta,
Mesenteric Vessels.

11. ELECTRONIC CO2 ENDOFLATOR
• It is an insufflation unit for delivering CO2 to
the peritoneal cavity for laparoscopy surgery.
• Maximum capacity to insufflate up to
15 – 20/min and to maintain an
intra – abdominal pressure of
12 -16 mmHg.

12. ELECTRONIC CO2 ENDOFLATOR
Important Insufflation parameters are:
1. Pre-set Insufflation Pressure : should be
approximately 12 – 14 mmHg
2. Actual Intra – abdominal Pressure : should never
exceed 25mm Hg as it would lead to compression of
IVC
3. Gas Flow Rate : initially it should be 1 – 2L/min
4. Total Volume of Gas Inflow : in normal size human
, 4 – 5L of CO2 is required for intra – abdominal
pressure of 12 mmHg

13. LIMITATIONS OF INSUFFLATOR
• Insufflator shows the intra abdominal
pressure , 4mmHg more than the actual
pressure
• If Intra abdominal pressure rises
> 25 mmHg, there is risk of:
1. Compression of IVC
2. Deep vein thrombosis
3. Air embolism
4. Surgical Emphysema

14. ENDOSCOPES
• It is state of art instrument which produces
images of the concealed body cavity.
• The rod lens system used in Endoscope was
introduced by professor Harold H Hopkins (
his photo) .
• Kurt Semm, father of modern gynaecologic
endoscopy, popularised used of endoscopes
for diagnostic purposes, invented the
insufflator , uterine manipulator amongst
other things.
Harold H Hopkins
Kurt Semm

15. ENDOSCOPES
• Endoscopes are available in various diameters,
length and angles
• Diameters available :
1.5 mm for micro laparoscopy,
5mm for diagnostic laparoscopy,
10mm for operative laparoscopy.
• Angles available:
0 (used in gynaecology), 30 , 45
• Flexible fiberscope provides allow the angle of
vision to be adjusted by active deflection of
the distal tip. They are used in digestive tract
or tumour surgery.

16. VIDEOENDOSCOPY
Single chip video camera
Three chip video camera
• In modern laparoscopy, a good video
camera is a must.
• The technical criteria of a good camera is
high resolution (pixels), sensitivity (lux), signal
–to – noise ratio, number and quality of
video output ports.
• Most important component is CCD sensor, a
solid state chip embedded with a series of a
tiny, light sensitive photosites capable of
producing various amount of charge on
incidence of light.

17. VIDEOENDOSCOPY
• In 2002, 1st generation of digital camera was
introduced in name of IMAGE1, which had
digital source sampling (DSS) technique.
• Camera should be focussed before
inserting, by focussing on a target area 5cm
away from camera and set the white
balance
• It is done by focussing on a white object.
Fully equipped video cart

18. VIDEOENDOSCOPY
IMAGE H3-Z, 3 chip high
definition camera : uses 1080p
(p stands for progressive scan).
It is the highest resolution for
distribution and broadcasting of
video content.
Advantage : Digital still images, video
and audio files can be used for
consultation, review , medicolegal
purposes and promotes ‘Telemedicine’.
AIDA: Advanced Image and Data
Archiving system provides an excellent
tool for data storage

19. VIDEO MONITOR
Flat screen high-definition (HD),
Video monitor WIDEVIEW HD
• Surgical monitors based on the principle
of Electronic Horizontal Linear Scanning.
• There are 3 main analogue television
broadcasting system: PAL, SECAM and
NTSC.
• NTSC has 525 lines of resolution, PAL and
SECAM works on 625 lines
• The final image depends upon no. of
lines of resolution, pixels and scanning
lines.

20. VIDEO MONITOR
• Optical vision is of paramount importance for
the outcome of any surgery
• Largest 23 inch LCD video monitor with 16:9
frames , improves anatomical orientation
rather than conventional 4:3 frames
• Other Advantages include better
• Visualisation of lateral aspects,
• Higher depth perception and
• better Contrast , resulting in
• better Differentiation of Anatomical Planes Comparison of 16:9 and 4:3 frames

21. LIGHT SOURCE AND CABLE
• Light source and cable is very important as
adequate illumination is necessary for video
laparoscopy and minimal invasive surgery.
• Light source is most important part of
electro- optical system.
• Light source mainly depends on the lamp. 2
types are available :-
Halogen and Xenon

22. LIGHT SOURCE AND CABLE
Cold light source XENON 300

23. LIGHT SOURCE AND CABLE
• Light source’s luminous efficacy is quotient of
the total luminous flux emitted divided by total
lamp power input
• 175 - 250 watt generally sufficient for routine
endoscopic procedure
• For miniature endoscopes, 300 watts of light
source is required as minimal bleeding
obscures the view

24. TELE PACK X
It is a compact unit consisting of light
source, Camera Control Unit, Monitor
and documentation Module. Other
features include
• 15" LED backlight display
• Image rotation
• 24 bit colour depth for natural colour
rendition
• DVI-D video output for connecting
external monitors
• High-performance LED light source
similar to Power LED 175

25. LIGHT SOURCE AND CABLE
• 2 type: Fibre optic and Liquid - crystal gel
cable
• Medical grade fibre optic cable consists of
Fibre Glass Bundles, surrounded by a cladding
layer which allows propagation of light by total
internal reflection.
• Diameter ranges from 3.5 mm – 6 mm
• Length ranges from 180cm – 300cm
• For general laparoscopy , a light cable of
5 mm diameter and 240cm length is used

26. LIGHT SOURCE AND CABLE
Fibre optic light cable
Fibre Optic Cable Liquid Crystal gel cable
Core has fibre optic bundles Has sheath filled with clear
like fluid
Fragile , glass optic fibre may
crack
Extremely fragile, due to
quartz at the ends
More flexible and transmits
less heat
Transmits 30% more light

27. LIMITATIONS OF IMAGING SYSTEM
• Endoscopes only provide a visual feedback and lacks tactile
feedback, resulting in deficiencies in eye – hand coordination.
• The traditional 4:3 video monitors lack proper depth perception
and anatomical orientation, as it creates only
2 dimensional image of body cavity.
• The cold light source emits harmful UV radiation
• A major drawback of light cables is the relative fragility.

28. FORCEPS AND SCISSORS
1. Connector pin for unipolar coagulation
2. Insulated metal outer sheath
3. Forceps insert
4. Handle
• A set ergonomics instrument is
perquisite of successful of
laparoscopic surgery.
• Most hand instruments can be
divided into : handle, insulated
metal sheath and working insert.
• Working insert may be a Forceps,
Grasper and Scissor.

29. FORCEPS AND SCISSORS
Various single action grasping forceps
Various double action grasping forceps
• Heat insulation can be made of
nylon or heat shrinkable plastic
• Hand instruments can be reusable
or disposable
• Diameter ranges from 3mm to
10mm
• Grasping forceps can be single
action (used in adhesiolysis) or
double action

30. FORCEPS AND SCISSORS
1. Straight scissors
2. Curved scissors
3. Scissors with serrated blade
4. Hook scissors
Straight scissors : used for mechanical
dissection and for cutting sutures.
Curved scissors : most commonly used scissors
in laparoscopy due its ergonomic advantage.
Scissors with serrated blade : used for cutting
slippery tissue.
Hook scissors : useful for transection of ducts,
arteries or ligaments.

31. NEEDLE HOLDER & SUTURING TECHNIQUES
• Advanced laparoscopic procedures can
be performed safely only with surgeon’s
suturing and knot tying technique.
• There are Two suturing methods:
• Intra-Corporeal and
Extra-Corporeal technique
• Another method is laparoscopic clip.
• Most of them are made of pure titanium
or of titanium alloys.

32. UNIPOLAR ELECTROSURGERY
Unipolar needle electrode
• In Unipolar Electro surgery, the active electrode
is at surgical site.
• The patient return electrode (grounding pad) is
elsewhere on the body.
• It may be used for coagulation, pure section
and coagulation – section by use of mixed
current.
• Coagulation current is intermittent current.
• Cutting current is continuous current.

33. UNIPOLAR ELECTROSURGERY
Various shape of Unipolar electrode are
available according to use
• Spatula : W shaped or Blunt tipped
• Hook : L- , J- , U- configuration
• Ball shaped
• Barrel shaped
• Straight
Blunt tipped is used for endometrial ablation

34. BIPOLAR ELECTROSURGERY
• In bipolar system, current flows from one
jaw (1st electrode) through the tissue to
other (2nd electrode).
• Flow of electrode is restricted to a smaller
area, so chances of iatrogenic injury, current
arching, capacitive coupling and direct
coupling is reduced.

35. BIPOLAR ELECTROSURGERY
• Coagulation in bipolar system is due to steep
increase of temperature in the tissues.
• There is risk of patient burns.
• Disposable and reusable, both kinds of Bipolar
instruments are available in various shapes.
• In gynaecological surgery, bipolar forceps of 3mm
width is preferred.
• Smaller the width of the electrode, lesser is the
thermal effect. So 1.5mm width is used in micro
electro surgery.

36. LIMITATION OF INSTRUMENTS
• The surgeon has limited range of motion at the surgical site
resulting in a loss of dexterity
• Surgeons must use tools to interact with tissue rather than
manipulate it directly with their hands, causing reduced judgement
• Reduced tactile sensation
• The tool endpoints move in the opposite direction to the
surgeon's hands due to the pivot point, making laparoscopic
surgery a non-intuitive motor skill that is difficult to learn
• This is called the Fulcrum effect

37. SUCTION AND IRRIGATION
Suction Irrigation system
Suction cannula
Suction cannula varies from 5mm (standard) to
10mm(used when haemoperitoneum > 1500ml)
Uses of suction and irrigation are:
• Lavage of abdominal cavity
• Control of bleeding
• Aspiration of clots
• Aspiration of fluid content of cysts
• Injection of vasoconstrictive agents
• Hydro dissection

38. UTERINE MANIPULATOR
• A uterine manipulator is used in the majority of advanced
laparoscopic-assisted gynaecological procedures, be it for
diagnostic assessment or surgical interventions.
• It facilitates visualization of the pelvic organs and permits
endoscopically-controlled injection of methylene blue in the case
of chromo-pertubation for assessment of tubal patency.

39. SUMMARY
Laparoscopic surgery or minimally invasive surgery (MIS) has
numerous advantages such as
less pain ,
less blood loss,
early recovery and
shorter hospital stay.

40. SUMMARY
• But the basic laparoscopy instruments has many
limitations
To enumerate a few are:
• The surgeon has limited range of motion at the surgical
site resulting in a loss of dexterity.
• Two dimensional image of the laparoscope with poor
depth perception
• Retraction of internal organs is a problem

41. TAKE HOME MESSAGE
Laparoscopy is a magical tool which has
revolutionised the gynaecologic surgery.
It has it’s own limitation that can be overcome by
dexterity of the operating surgeon.
-Dr Niranjan Chavan