EXTENSIVE COVERAGE OF LAPAROSCOPIC INSTRUMENTS AND THEIR ERGONOMICS TO HELP SURGEONS TO KNOW HOW TO USE THEIR LAP INSTRUMENTS IN MOST APPROPRIATE WAY AND THEIR ERGONOMICS TO BE COMFERTABLE DURING SURGERY AND PATIENTS LIFE ALSO MORE SAFE.
LAPAROSCOPIC HAND INSTRUMENTS, ACCESSORIES AND ERGONOMICS
1. Dr. Ajay Jain
MBBS, MS, FIAGES, FMAS, FALS
ASSOCIATE DIRECTOR ,DEPT. OF GENERAL &
MINIMAL ACCESS SURGERY
MAX SUPERSPECIALITY HOSPITAL ,VAISHALI
,GHAZIABAD
Dr. Anubhav Singh
MBBS, DNB(General & Laparoscopic Surgery)
RESIDENT SURGEON, DEPT. OF GENERAL &
2. LAPAROSCOPIC PROCEDURES ARE INHERENTLY
COMPLEX
VISUALIZATION & TACTILE EXPLORATION OF
OPERATIVE FIELD IS INDIRECTLY ACHIEVED
THROUGH OPTICAL SYSTEMS & INSTRUMENTS
EQUIPMENT & INSTRUMENTATION HAVE GREATER
IMPACT & IMPORTANCE
SURGEON MUST BE FAMILIAR WITH EQUIPMENT TO
USE , TROUBLE SHOOT & SOLVE PROBLEMS
5. LIGHT SOURCE
HALOGEN -250 WATT LAMP
XENON- 175 / 300 WATT
LED
LIGHT INTENSITY REGULATED MANUALLY OR
AUTOMATICALLY
Brightest to darkest measured in units of decibels.
White balance by making sure white is correct then all the
colours through the spectrum are correct.
7. CAMERAS
SINGLE CHIP CAMERA – RESOLUTION 480-600 LINES
THREE CHIP CAMERA –RESOLUTION MORE THAN 750
HORIZONTAL LINES
DIGITAL THREE CHIP CAMERA – WITH INTEGRATED
IMAGE PROCESSING MODULES
8. CHIP: THIS IS ALSO CALLED A CHARGED COUPLED
DEVICE ( CCD )
THESE ARE FLAT SILICONE WAFERS WITH A MATRIX, A
GRID OF MINUTE IMAGE SENSORS
CALLED PIXELS.
HD (1280 x 720 p resolution )
FULL HD CAMERA (1920 x 1080 p resolution)
3D CAMERA
4k UHD CAMERA (4096 x 2160 p resolution)
8k UHD CAMERA (7680 x 4320 p resolution)
Camera head consists of a goal lens , a prism assembly and
three sensors for acqurining the primary colours of the
image.
9. MONITORS
GENERATE HIGH RESOLUTION IMAGES
THROUGH S-VHS / COMPOSITE / DVI
CONNECTION
LARGE SCREEN 20” OR MORE PREFERRED
NON FLICKERRING
11. GASES FOR PNEUMOPERITONEUM
IDEAL GAS : COLOURLESS , PHYSIOLOGICALLY INERT ,
NON EXPLOSIVE IN PRESENCE OF ELECTROCAUTERY
OR LASER COAGULATION
HIGHLY SOLUBLE IN BLOOD
READILY AVAILABLE , INEXPENSIVE & NON TOXIC
CO2 IS MOST COMMONLY USED – ODOURLESS ,
COLOURLESS , READILY AVAILABLE , STABLE ,
NATURALLY FOUND IN TISSUES & SUBSEQUENTLY
ELIMINATED BY LUNGS
OTHER GASES USED ARE NITROUS OXIDE, HELIUM,
ARGON
12. LAPAROFLATOR
ELECTRONIC CO2 LAPAROFLATOR
IS INSUFFLATION UNIT
ALLOWS PRESET PRESSURE &
FLOW
INSUFFLATION FLOW RATE VARIES
FROM 1-40LITRES PER MINUTE
NEWER ONES DELIVER
HUMIDIFIED/ WARM GAS TO
REDUCE FOGGING OF LENS
13. SUCTION IRRIGATION MACHINE
USED FOR FLUSHING &
CLEANING ABDOMINAL CAVITY
DESIGNED FOR USE WITH 26173
AR SUCTION / INSTILLATION
TUBE
SUCTION IRRIGATION HAND
INSTRUMENT :
SIZES COME IN 5/10MM
DIAMETERS
USED FOR INTERMITTENT
SUCTION & BLUNT DISSECTION
14. OPERATIVE HAND INSTRUMENTS
VERESS NEEDLE
USED FOR CREATING
PNEMOPERITONEUM
CONSISTS OF OUTER CANNULA &
BEVELED NEDDLE POINT FOR
CUTTING THROUGH TISSUE , INNER
STYLET LOADED WITH SPRING WITH
LATERAL HOLE
EXTERNAL DIAMETER 2.2MM &
INTERNAL 1.2MM
SIZES : 80 MM ( PEDIATRIC ) / 100 MM
/ 120 MM ( OBESE )
15. HASSAN CANNULA
A SAFETY CANNULA
CONSISTS OF CONE SHAPED SLEEVE METAL OR
PLASTIC SHEATH WITH TWO TRUSTS FOR
AFFIXING FASCIAL SUTURES
TRUMPET OR FLAP VALVE
BLUNT TIP OBTURATOR
16. TROCARS
THE TROCAR HAS A BLADE WITH A SHAFT AND BODY.
REUSABLE :
COMBINATION OF METAL & PLASTIC
TIP HAS TWO EDGED BLADE WHICH EFFECTIVELY
PENETRATES THE ABDOMINAL WALL
DISPOSABLE :
HAS SPRING LOADED MECHANISM WHICH
WITHDRAWS SHARP TIP IMMEDIATELY AFTER IT
PASSES THROUGH THE ABDOMINAL WALL
DIFFERENT TIPS :
3EDGED PYRAMIDAL
FLAT TWO EDGED BLADE
CONICAL
DIAMETRS : 3-30MM
COMMONLY USED 5-10MM
17. ALL TROCARS HAVE VALVE
MECHANISM AT THE TOP
MANUAL OR AUTOMATIC,
WHICH ALLOWS INTRUMENT’S
PASSAGE IN AND OUT & ALLOWS
INTERNAL AIR SEAL
END OF CANNULA IS STRIGHT OR
OBLIQUE
OBLIQUE : BETTER FOR PASSAGE
OF INSTRUMENT
EXCEL TROCARS HAVE UNIQUE
DESIGNS AND FEATURES SUCH
AS DIRECT SERIAL INCISION OF
TISSUE UNDER VISUAL CONTROL
18. REDUCTION SLEEVE
REDUCE SIZE OF PORT FROM 10-5
OR 5-3 TO MAINTAIN
PNEUMOPERITONEUM
WHENEVER SURGEON CHANGES
INSTRUMENT FROM LARGER TO
SMALLER DIAMETER
19. NEEDLE HOLDER
LAPROSCOPIC NEEDLE HOLDERS ARE AVAILABLE
WITH
STRAIGHT
CURVED TIP
ERGONOMICS BETTER IN INLINE GRIP > PISTOL GRIP
21. OTHER HAND INSTRUMENTS
DISPOSABLE OR REUSABLE
REUSABLE ARE EXPENSIVE INITIALLY BUT ARE
COST EFFECTIVE, DISMOUNTABLE : CAN BE
WASHED AND CLEANED PROPERLY
DISPOSABLE ARE NOT DISMOUNTABLE, NOT
STERILISED PROPERLY
DIAMETER VARIES FROM 1.8-12MM
MAJORITY DESIGNED TO PASS THROUGH 5-10MM
CANULA
LENGTH VARIES 18-45cms (28 FOR PEDIATRICS;
36CMS IN ADULTS AND 45 CMS IN OBESE)
22. FOR BETTER ERGONOMICS HALF INSTRUMENT
SHOULD BE INSIDE HALF OUTSIDE TO STABILIZE
THE PORT NICELY; BEHAVES LIKE CLASS 1 LEVER
MOST INSTRUMENTS LIKE SCISSORS AND
GRASPERS HAVE OPENING AND CLOSING
FUNCTION
MOST OF THEM CAN ROTATE AT 360 DEGREE
ANGLE
24. MOST OF THESE INSTRUMENTS HAVE THREE
DETACHABLE PARTS
1. HANDLE
2. INSULATED OUTER TUBE
3. INSERT WHICH MAKES TIP OF
INSTRUMENT
25. DIFFERENT HANDLES
LOCKS AND WITHOUT LOCK
LOCKING MECHANISM IS INCORPORATED IN
HANDLE WHERE TISSUE NEEDS TO BE GRIPPED
FIRMLY SO THAT SURGEON CAN LOCK OR UNLOCK
EASILY
PREVENTS FATIGUE ON PROLONGED USE
HAS RACHETS SO AS TO CLOSE IT IN DIFFERENT
POSTIONS AT DIFFERENT PRESSURE
INSTRUMENT HANDLES HAVE ROTATOR MECHANISM
TO ROTATE THE TIP AND ATTACHMENT FOR
UNIPOLAR OR BIPOLAR ELECTRO SURGICAL LEAD
26. CUSCHIERI BALL HANDLE WAS INVENTED BY SIR
ALFRED CUSCHIERI
LIES COMFORTABLY IN SURGEONS PALM;
REDUCES FATIGUE AND EASES ROTATION
WITHIN PALM RATHER THAN AT WRIST
27. INSULATED OUTER TUBE
INSULATION SHOULD BE GOOD TO PREVENT
ACCIDENTAL OR ELECTRIC BURNS TO BOWEL OR
OTHER VISCERAS
MADE OF SILICON OR PLASTIC
PINHOLE BREACH IS NOT SEEN WITH EYES BUT
COULD BE DANGEROUS AT THE TIME OF
ELECTROCAUTERY
28. INSERT
VARIES ON TIP-GRASPERS ,SCISSORS ,FORCEPS
SINGLE ACTION JAW- OPENS LESS BUT CLOSES
WITH MORE FORCE
DOUBLE ACTION JAW-WIDE OPENING, LESS
FORCE REQUIRED TO CLOSE
29. GRASPERS
DIFFERENT TYPES OF GRASPERS ARE AVAILABLE
LIKE ATRAUMATIC BOWEL GRASPERS
GOOD WHEN WORK IS DONE IN SINLGE PLANE
IN CONTROLLED MANNER PARTICULARLY IN
ADHESIOLYSIS
32. SPATULA/HOOK/ULTRASONIC SHEAR
SPATULA HAS FLAT TIP FOR
DISSECTION
HOOK HAS L SHAPED TIP USED
FOR SHARP DISSESCTION AND
WIDE ANGLE FOR HEMOSTASIS
HARMONIC SCALPEL FOR
ADVANCED PROCEDURES
35. ERGONOMICS
WORD DERIVATION- ERGON (LABOR) NOMIA
(ARRANGEMENT)
CONCEPT: OF DESIGNING THE WORKING
ENVIRONMENT TO FIT THE WORKER INSTEAD OF
FORCING THE WORKED TO FIT THE ENVIRONMENT
APPLICATION: TO MAKE OT MORE USER FRIENDLY,
TO REDUCE STRESS, TO INCREASE EFFICIENCY AND
SAFETY
INCLUDES INSTRUMENTS MACHINES AND OT
DESIGNS
36. INVLOVES UNDERSTANDING INTERACTION
BETWEEN HUMANS AND OTHER ELEMENTS IN
THE SYSTEM TO OPTIMISE HUMAN WELL BEING
AND OVER ALL PERFORMANCE OF THE SYSTEM
37. ERGONOMIC VARIABLE
IMPORTANT VARIABLES WHICH HAVE BEEN
STUDIED INCLUDE
HAND SIZE
HANDLE TO TIP FORCE TRANSMISSION
OPTIMUM HEIGHT OF SURGEONS HAND
HEIGHT OF OPERATING TABLE
VIEW SITE IN RELATION TO MONITOR POSITION
TECHNIQUE OF GRIPPING INSTRUMENTS
38. Open Surgeon Vs Lap Surgeon
How do they differ?!
Open Surgeon
• Fast
• Hand is as good as eyes
• Dissection precedes
• Ergonomics: Optional
Laparoscopic Surgeon
• Slow and steady
• Stop when you don’t see
• Haemostasis precedes
• Ergonomics: Vital
39. HAND SIZE
LAP SURGEONS USING GLOVE SIZE 6.5 OR LESS
EXPERIENCE MUSCULOSKELETAL PROBLEMS
40. TECHNIQUE OF GRIPPING
PALM GRIPPING HAND POSITION WITH A PISTOL
HANDLE IS MORE EFFICIENT THAN FINGER IN
RING GRASP
IMPROPER GRIPPING CAUSES NEUROPRAXIA AND
COMPLICATIONS OF NERVE INJURY
42. MONITOR POSITIONING
MISALIGNMENT OF EYE- HAND- TARGET AXIS
BECAUSE OF LIMITED FREEDOM IN MONITOR
POSITIONING IS RECOGNISED AS ERGONOMIC
DRAWBACK
REALIGNMENT IMPROVES COMFORT, SAFETY
AND EFFICIENCY
IN HORIZONTAL PLANE MONITOR SHOULD BE
STRAIGHT IN FRONT OF EACH PERSON AND
ALIGNED WITH A FOREARM- INSTRUMENT
MOTOR AXIS TO AVOID AXIAL ROTATION OF
SPINE
44. IN SAGITTAL PLANE MONITOR SHOULD BE
POSITONED AT OR WITHIN 25 OPTIMAL DEGREES
BELOW THE HORIZONTAL PLANE OF THE EYE TO
AVOID NECK EXTENSION
2ND MONITOR FOR ASSISTANT REDUCES STRAIN
ON CERVICAL SPINE
MONITOR SHOULD BE PLACED 4-8 FT FROM
OPERATING SURGEON
49. TROCAR PLACEMENT
PORTS ARE PLACED IN PRINCIPLES OF
TRIANGULATION
TARGET ORGAN SHOULD BE 15-20CM FROM
CENTRE PORT
2 REMAINING TROCARS ARE PLACED IN THE
SAME 15-20CM ARC AT 5-7CM ON EITHER SIDE OF
THE OPTICAL TROCARS
IF REQUIRED, 2 MORE PORTS CAN BE PLACED IN
THE SAME ARC
IN SILS, TRIANGULATION IS ACHIEVED THROUGH
CURVED INSTRUMENTS
59. Ideal Relaxed Position
-straight head, in the axis of the trunk,
without rotation or extension of the cervical
spine;
- shoulders in a relaxed and neutral position;
- arms alongside the body
- elbows bent to 70 to 90 degrees
- forearms in an horizontal or slightly
descending axis-
-hands pronated (physiological resting
position);
- hands and fingers lightly grip the
handles/handpiece
•Waist line table
•Gaze down view of monitor
•Straight line principle
•Triangulation
60. To be an efficient Surgeon…
Concentrate on
Equipments
Environment
61. OT LAYOUT
OT LAYOUT IS PLANNED ACCORDING TO PROCEDURE
ALLOWS UNOBSTRUCTED MOVEMENT OF OT
PERSONNEL AND SURGEON
FOOT PEDALS SHOULD BE EASY REACH AND IN AXIS
WITH OPERATING FORCE TO PREVENT TORSION OR
STRAIN ON FOOT
SHOULD BE ADEQUATELY ELIMINATED TO PREVENT
STRAIN ON EYES
CABLES AND WIRES SHOULD BE FLUSHED WITH THE
GROUND AND COVERED WITH INSULATED DUCT
62. USE OF LAPAROSCOPY IS ASSOCIATED WITH
SIGNIFICANT ERGONOMIC PROBLEMS HENCE
PROPER TRAINING AND AWARENESS IS
ESSENTIAL THUS MAKING IT SAFER FOR BOTH
SURGEONS AND PATIENTS
