2. Laparoscopy is a technologically dependent surgery.Laparoscopy is a technologically dependent surgery.
Computerized designing of laparoscopic instrumentsComputerized designing of laparoscopic instruments
Microprocessor controlled safety featuresMicroprocessor controlled safety features
A laparoscopic surgeon should be technically well acknowledgedA laparoscopic surgeon should be technically well acknowledged ofof
the principle of the instrumentthe principle of the instrument being usedbeing used, and should not always depend, and should not always depend
upon their technical team should an emergency arrive.upon their technical team should an emergency arrive.
5. Insufflation systemsInsufflation systems
Insufflation system allows gas to fill the abdominopelvicInsufflation system allows gas to fill the abdominopelvic
cavity to optimize visualization.cavity to optimize visualization.
Insufflators are designed to deliver gas at low rates duringInsufflators are designed to deliver gas at low rates during
initial Veres needle insertion, but are also able to provide highinitial Veres needle insertion, but are also able to provide high
flow rates when gas is lost to maintain a relatively constant setflow rates when gas is lost to maintain a relatively constant set
intraabdominal pressure during surgery.intraabdominal pressure during surgery.
Insufflation tubing with a 0.3micron filter is recommended toInsufflation tubing with a 0.3micron filter is recommended to
prevent intraperitoneal contamination with bacteria,prevent intraperitoneal contamination with bacteria,
microparticles and debris from insufflator and gas tank.microparticles and debris from insufflator and gas tank.
6. Veress needleVeress needle
Spring loadedSpring loaded
Blunt tip retractable into sharp sheathBlunt tip retractable into sharp sheath
Small caliber penetrates tissues by separatingSmall caliber penetrates tissues by separating
rather than cuttingrather than cutting
Disposable or reusableDisposable or reusable
Diameter 2mm and length 12-15cmDiameter 2mm and length 12-15cm
Insufflation upto 2.5L/minInsufflation upto 2.5L/min
10. Insufflation and abdominal liftingInsufflation and abdominal lifting
systemssystems
Gases used for insufflationGases used for insufflation ::
Filtered room airFiltered room air
Carbon dioxideCarbon dioxide – commonly used , has advantage of being– commonly used , has advantage of being
rapidly absorbed by blood, non toxic, cost effective and can berapidly absorbed by blood, non toxic, cost effective and can be
used with cauteryused with cautery
Nitrous oxideNitrous oxide
HeliumHelium
Gasless laparoscopyGasless laparoscopy can be performed with the use of acan be performed with the use of a
mechanical lifting arm that attaches to a fanlike retractor alongmechanical lifting arm that attaches to a fanlike retractor along
the peritoneal surface of the abdominal wall . This approachthe peritoneal surface of the abdominal wall . This approach
favoured in patients with cardiopulmonary risk factors.favoured in patients with cardiopulmonary risk factors.
11. InsufflatorsInsufflators
1966-Kurt Semm introduced the concept1966-Kurt Semm introduced the concept
-Automatic-Automatic
-Manual-Manual
Indicators-Intra abdominal pressureIndicators-Intra abdominal pressure
-Flow rate-Flow rate
-Total gas used-Total gas used
-Cylinder capacity-Cylinder capacity
ThermoflatorThermoflator
-Upto 20L/Min-Upto 20L/Min
14. Trocars and Cannulae/SleevesTrocars and Cannulae/Sleeves
Used to pierce the abdominal wall for placement ofUsed to pierce the abdominal wall for placement of
laparoscope and surgical instrumentlaparoscope and surgical instrument
Available as disposable or reusable systemsAvailable as disposable or reusable systems
Trocar tips can be pyramidal, conical, blunt tipped, orTrocar tips can be pyramidal, conical, blunt tipped, or
have optical accesshave optical access
Sizes vary from 3mm to 10mmSizes vary from 3mm to 10mm
Hassons trocar and cannulaeHassons trocar and cannulae
Expandable trocar sheaths are now availableExpandable trocar sheaths are now available
22. IMAGING SYSTEMIMAGING SYSTEM
Consists of :Consists of :
LaparoscopeLaparoscope
Camera unitCamera unit
Fiberoptic cordFiberoptic cord
Light sourceLight source
MonitorsMonitors
23. Laparoscope (Telescope)Laparoscope (Telescope)
British physicist Hopkins invented in 1952British physicist Hopkins invented in 1952
Conventional Thin lens System separated by airConventional Thin lens System separated by air
Present day scopes have series of rod lens in centre with rim of opticalPresent day scopes have series of rod lens in centre with rim of optical
fibers on outer aspectfibers on outer aspect
Rod Hopkins System provides excellent field of vision with minimalRod Hopkins System provides excellent field of vision with minimal
distortiondistortion
END ON VIEW
OUTER SHEATH
LIGHT
CONDUCTING
FIBRES
THE LENS CHAIN
24. TypesTypes
Based on size and angle of visionBased on size and angle of vision
Size varies from 0.8 to 12mmSize varies from 0.8 to 12mm
Routine use 10mm scopeRoutine use 10mm scope
5mm scope transmits 10% light of 10mm scope5mm scope transmits 10% light of 10mm scope
3mm scopes in paediatric practice3mm scopes in paediatric practice
Based on angleBased on angle
0 -Forward viewing0 -Forward viewing
30 -Angled30 -Angled
45 -Angled45 -Angled
25.
26. Advantages of angled scopesAdvantages of angled scopes
Unobstructed view of dissecting area from distanceUnobstructed view of dissecting area from distance
More space for instrument maneuverabilityMore space for instrument maneuverability
Ability to look around the cornersAbility to look around the corners
DisadvantagesDisadvantages
More difficult to operateMore difficult to operate
Flexible and semi flexible scopesFlexible and semi flexible scopes
Fiber optic basedFiber optic based
Digital CCD camera basedDigital CCD camera based
27. Fogging of LensFogging of Lens
FoggingFogging :: due to increased temp. in abdomendue to increased temp. in abdomen
PreventedPrevented by dipping tip in warm water (atby dipping tip in warm water (at
6060ºCºC) & by touching liver / Abdominal Wall.) & by touching liver / Abdominal Wall.
Use of Antifog solutionsUse of Antifog solutions
28. The CameraThe Camera
Most important and vital partMost important and vital part
The sensor called CCD (Charged –Coupled Device) has smallThe sensor called CCD (Charged –Coupled Device) has small
pieces of silicon called pixels, arranged in rows and columnspieces of silicon called pixels, arranged in rows and columns
and are sensitive to lightand are sensitive to light
Single chipSingle chip
Monitor resolution 400-450 linesMonitor resolution 400-450 lines
Three chipThree chip-----analog/ digital.-----analog/ digital.
Light split into RGB spectrum by prism in head of camera.Light split into RGB spectrum by prism in head of camera.
Analog=GB-700 to 750 lines—medical monitorAnalog=GB-700 to 750 lines—medical monitor
Digital=Enhanced quality-1000 to 1200 lines like HDTVDigital=Enhanced quality-1000 to 1200 lines like HDTV
29. White balancingWhite balancing
Zoom optionZoom option
Digital enhancementDigital enhancement
Creates sharper image and contrastCreates sharper image and contrast
enhancementenhancement
Disadvantage is development of grainsDisadvantage is development of grains
that distort quality of imagethat distort quality of image
Disadvantage of present day Cameras is 2D visionDisadvantage of present day Cameras is 2D vision
Absence of depth perceptionAbsence of depth perception
3D Cameras3D Cameras
Prohibitive costProhibitive cost
No clear cut benefitNo clear cut benefit
33. Light CablesLight Cables
Two typesTwo types
1.Fluid filled cables1.Fluid filled cables
2.Fiber optic cables2.Fiber optic cables
Fluid filled cableFluid filled cable
-Conduct more heat-Conduct more heat
-Stiffer nature-Stiffer nature
-Causes hinderance in maneuvering angled scopes-Causes hinderance in maneuvering angled scopes
-Inability to autoclave-Inability to autoclave
Fiber opticFiber optic
-More user friendly-More user friendly
-Fragile to be handled with care-Fragile to be handled with care
-Fiber damage of >25% to replace cable-Fiber damage of >25% to replace cable
34. LIGHT CABLESLIGHT CABLES
Fibreoptics - Multiple coaxial QuartzFibreoptics - Multiple coaxial Quartz
Fibres,Fibres, transmit light bytransmit light by totaltotal
internal reflectioninternal reflection..
Random or incoherent bundles transmitRandom or incoherent bundles transmit
light.light.
Orientated or coherent bundles transmitOrientated or coherent bundles transmit
an image.an image.
Filler material that binds the bundlesFiller material that binds the bundles
absorbs the heat and there is 30% loss inabsorbs the heat and there is 30% loss in
illuminosity ( "lux" )illuminosity ( "lux" )
New 'fluid light" cables without fillerNew 'fluid light" cables without filler
material avoids this.material avoids this.
35. MonitorMonitor
Should support the resolution of the cameraShould support the resolution of the camera
Standard resolution monitors have a resolutionStandard resolution monitors have a resolution
of 400 linesof 400 lines
High definition monitors-1200 linesHigh definition monitors-1200 lines
38. Hand InstrumentsHand Instruments
Usually around 33cm longUsually around 33cm long
Main partsMain parts
-Handles-Handles
-Shaft with insulation-Shaft with insulation
-Inner effector part-Inner effector part
Prerequisites for ideal Reusable instrumentsPrerequisites for ideal Reusable instruments
1.Jaws to be adequately elastic to perform atraumatic handling1.Jaws to be adequately elastic to perform atraumatic handling
2.Easy to disassemble and reassemble2.Easy to disassemble and reassemble
3.Parts should be interchangeable between similar instruments3.Parts should be interchangeable between similar instruments
4.Cleaning and sterilization to be easy4.Cleaning and sterilization to be easy
5.Simple design with minimum number of hinges and bolts5.Simple design with minimum number of hinges and bolts
39. OPERATING INSTRUMENTSOPERATING INSTRUMENTS
Follow the general pattern of being “take apart”, withFollow the general pattern of being “take apart”, with
insulated sheaths,insulated sheaths,
central working device,central working device,
a handle with a ratchet,a handle with a ratchet,
with rotary capability at the working end.with rotary capability at the working end.
57. LIGASURE – Vessel SealingLIGASURE – Vessel Sealing
SystemSystem
Provides a combination of pressure and energy to create vessel fusionProvides a combination of pressure and energy to create vessel fusion
Permanently fuses vessels up to and including 7 mm in diameter and tissuePermanently fuses vessels up to and including 7 mm in diameter and tissue
bundles without dissection or isolationbundles without dissection or isolation
Average seal cycle is 2 to 4 secondsAverage seal cycle is 2 to 4 seconds
Seals withstand three times normal systolic blood pressureSeals withstand three times normal systolic blood pressure
Feedback-controlled response system automatically discontinues energyFeedback-controlled response system automatically discontinues energy
delivery when the seal cycle is complete, eliminating the guessworkdelivery when the seal cycle is complete, eliminating the guesswork
How It Works An ultrasonic wave is created by applying electromagnetic energy from the Generator 300 to a piezoelectric transducer located between metal cylinders in the hand piece. In response to the electric field, the waves, traveling as sine waves from the hand piece to the blade, create mechanical vibrations. Silicon rings are located on the positions of the blade where the amplitude of the wave is zero in order to guide the blade. 2 These mechanical vibrations then drive the active blade of the device. Vibrating 55,500 times per second, when the blade comes into contact with the tissue and pressure is applied, the blood vessels are coapted. This coaptation breaks up positive hydrogen molecules, denaturing the protein in the cells. The denatured protein then forms a sticky coagulum, which forms a hemostatic seal, allowing the surgeon to simultaneously cut and coagulate. What It Does Harmonic devices have four qualities of action: cutting, coagulation, coaptation, and cavitation. These actions can be achieved singularly or in combination with one another. In surgical procedures, all of these effects are typically applied consecutively. 2 Cutting Unlike electrosurgery, which uses extreme local heat to vaporize and disrupt tissue, Harmonic devices use a combination of tension and pressure to rapidly stretch tissue. When the tissue reaches its elastic limit, the blade or device tip is able to cut smoothly through it. 2 Coaptation Coaptation, or the adherence of tissue, is achieved by Harmonic devices disrupting hydrogen bonds, causing collagen molecules to collapse and adhere to one another at a low temperature. The tissue is then transformed into a sticky coaptate. For the preliminary control of vessels in preparing for surgery, coaptation and pressure are key.2 Coagulation By applying ultrasound energy to tissue a few seconds longer than it takes to achieve coaptation, a rise in temperature leads to the release of water vapor and then to coagulation (maximum temperature of 150°C). Rather than defragmenting protein molecules as with coaptation, coagulation is achieved by denaturizing protein. Cavitation A side effect of the ultrasonic waves used to cut, coapt, and coagulate, cavitation occurs when the high-frequency vibration of a Harmonic device is transmitted to the surrounding tissue, causing rapid volume changes of the tissue and cell fluid. Vapor bubbles are then formulated at body temperature. 2 Cavitation effect aids in tissue plane dissection, and dissecting tissue planes enhances visibility in the operative field, which can be especially beneficial in anatomically remote regions or near vital structures. 2
Provides a combination of pressure and energy to create vessel fusion Permanently fuses vessels up to and including 7 mm in diameter and tissue bundles without dissection or isolation Average seal cycle is 2 to 4 seconds* Seals withstand three times normal systolic blood pressure Feedback-controlled response system automatically discontinues energy delivery when the seal cycle is complete, eliminating the guesswork
