1. SET UP FOR LAPAROSCOPIC SURGERY
EQUIPMENTS AND INSTRUMENTS
PRESENTER: DR. RAMADHANI ALLY IDDI
Resident-G/Surgery
MODERATOR: DR. RICHARD THOMAS
Gastroenterology Surgeon
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2. Session Objectives
Its expected that at the end of this session,
participants will be able to;
• Identify the common instruments and
equipments used in laparoscopic surgery
• Describe the set up of laparoscopic surgery
• Describe ergonomics in relation to
laparoscopic surgery
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3. Introduction
• Laparoscopic surgery has three (3) main
components namely;
–Image production (light source, telescope
and camera).
–Pneumoperitoneum - insufflation of carbon
dioxide gas to create space for operation.
–Laparoscopic instruments.
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4. Image production equipments
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5. Image production equipments
• Include:
–Telescope
–Light source and cable
–Video camera
–Television monitor
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6. Telescope
• This is a rod lens system.
• Made of surgical stainless steel with an optical
lens train comprised of precisely aligned glass
lenses and spacers.
• It comprises of the objective lens and
eyepiece.
• Objective lens is at the distal tip of the rigid
endoscope, and determines the viewing angle.
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7. Telescope cont…..
• The eyepiece or ocular lens, remains outside
of the patient’s body and attaches to a camera
to view the images on a video monitor.
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8. Telescope cont…..
• The diameter of laparoscopes varies from 3 mm
to 12 mm
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3mm
5mm
10mm

9. Telescope cont…
objective lens at the
distal end offers an
angle of view from 0
to 120 degrees.
• 0º provides a field of
view of 76º
• 30º provides a total
field of view of 152º
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10. Telescope cont…
• There are telescopes with an integrated
instrument channel.
• Generally are 0º straightforward scopes.
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11. Telescope cont…
• Uses:
– Diagnostic laparoscopy
– Tissue fragments or biopsy specimens can also be
extracted with the aid of a grasping forceps.
• Disadvantage:
–Deterioration in image quality.
This is due to the lower light intensity that can be
picked up by the video
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12. Light source
• High-intensity light is created with bulbs of
halogen gas, xenon gas or mercury vapor.
• The bulbs are available in different potencies
(150 and 300 Watts)
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13. Light cable
• Light is transmitted from the light source to
the laparoscope and operative field through
light cables.
• There are two (2) types of cables:
- Fiber-optic
- Liquid crystal gel cables.
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14. Light cable cont….
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Fibreoptic cable
Fibreoptic light cable

15. Light cable cont….
• Fiberoptic cables are made up of a bundle of
optical fiber glass.
– Light transmission is by total internal reflection.
– The quality of light depends on the number of
light fibers and diameter cable.
• Advantages: Little light loss
• Disadvantages:
– Do not transmit precise light spectrum
– Less durable, because, some optical fibers break
with continuous usage.
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16. Light cable cont….
Liquid crystal gel cables
• Made more rigid by a metal sheath
• Advantage: transmit a complete spectrum of
light
• Disadvantage:
–Less flexible
–More difficult to maintain and store. Need
only soaking sterilization (no gas
sterilization)
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17. Video Camera
• This essentially functions as an electronic
retina consisting of an array of light-sensitive
silicon elements
• Each silicon element contributes one unit
(referred to as a pixel) to the total image.
• The clarity of the image depends upon the
number of pixels on the chip.
• Standard cameras in laparoscopic use contain
250,000 to 380,000 pixels.
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19. Television Monitor
• High-resolution video (HD) monitors are
required for suitable reproduction of
endoscopic image from the high-definition
camera.
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20. Television Monitor cont…..
• The medical industry has adopted the flat-
panel monitors whose resolution determines a
better image
• Two separate monitors on each side of the
table are commonly used for most
laparoscopic procedures.
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21. Video Recording Systems
• The video recording systems document and
record the performed procedures.
• They are of paramount importance for
scientific and educational purposes.
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22. Television Monitor cont…
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23. Laparoscopic tower
at MNH
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24. Instruments for creation of
pneumoperitoneum
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25. 1901 – 1st laparoscopic pneumoperitoneum
established (George Kelling)
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26. CO2 Gas Insufflator
• The creation of working space in the
abdominal cavity is generally done using CO2
delivered via an automatic, high flow, pressure
regulated insufflator.
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27. CO2 Gas Insufflator cont…
• It also regulates the intra-abdominal pressure
and stops delivery of CO2 when the pressure
exceeds the predetermined level of
12-15 mmHg.
• Higher pressures have risks of;
– Hypercarbia
– Acidosis
– Adverse hemodynamic and pulmonary
effects
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28. CO2 Gas Insufflator cont…
• CO2 is currently the agent of choice.
• Advantages:
–Low risk of gas embolism
–Low toxicity to peritoneal tissues
–Rapid reabsorption
–Low cost
–Inhibits combustion.
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29. CO2 Gas Insufflator cont…
• Nitrous oxide:
–Has unpredictable absorption
characteristics
–May support combustion
• Helium: is inert but has a significant risk of gas
embolism.
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30. Instruments for Access
• Veress needle: introduced by Raol Palmer; a
French gynaecologist in 1947
• Hasson’s canula: Introduced by Hasson
• Trocars: introduced by JR.Dingfelder; an
American surgeon in 1978
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31. Veress Needle
• It is used to create the initial
pneumoperitoneum.
• It has two (2) components;
1.Outer hollow needle with a sharp beveled
edge
2.Inner, spring-loaded, retractable blunt
obturator.
• It is hollow with a side hole near its tip to
allow insufflation with air.
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32. Veress Needle cont….
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33. Veress Needle cont….
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80 mm
100 mm
120 mm

34. Veress Needle cont….
• During insertion of the veress needle into the
peritoneal cavity;
– Resistance at the fascia causes the blunt tip to
retract backwards enabling penetration by the
sharp outer needle.
• Once the cutting edge penetrates freely into
the peritoneal cavity;
– The blunt stylet springs forward beyond the
cutting edge preventing injury to intraperitoneal
structures.
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36. Hasson’s cannula
• The Hasson’s cannula is used for gaining initial
access to the abdominal cavity with an open
cutdown technique.
• It has a conical blunt tip that is fitted into the
cut down site and buttressed in place with
fascial sutures attached to the wings of the
cannula.
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38. Optical trocar
• Allows visualization of the tissues as the blade
cuts through the layers of the abdominal wall.
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39. Trocars
• The trocars establish a small interface
between the surgeon and the surgical field.
• The trocars give surgeons the accesses into
the abdominal cavity by establishing a shaft
and support for different instruments.
• It has outer hollow sheath and inner trocar.
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40. Trocars cont….
• Outer hollow sheath or cannula that has;
–Valve to prevent the CO2 gas from escaping
–Side port for instillation of gas
• Inner removable trocar fits through the outer
sheath and is used while inserting the port
through the abd. wall
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41. Trocars cont….
• Trocars are numbered as per outer diameter
i.e. 10mm, 7mm and 5mm
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10mm
7mm
5mm

42. Trocars cont….
• Trocars have;
–Valve (flapper or trumpet valve) to prevent
gas leaks during exchange of instruments.
–A side opening for connection to the gas
source.
• Reducer: used to convert a larger port into
smaller port i.e. 10mm to 5mm port
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43. Trocars cont….
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44. Gasless laparoscopy
• Used in high-risk patients with;
–Compromised cardio-respiratory function
–Decreased diaphragmatic splinting
• It facilitates continuous suction and use of
some conventional open instruments.
• The exposure may be sub-optimal due to tent
like retraction of the abdominal wall.
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45. Gasless laparoscopy cont…
• There may be localized trauma to the
abdominal wall, parietal peritoneum resulting
in more pain.
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46. Operative instruments
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47. Grasping and Dissecting
instruments
• Grasping forceps have been designed for
tissue manipulation (holding+haemostasis)
• The handle may be locking (ratcheted) or
non-locking (non-ratcheted).
• Length: 30-40cm long
• Diameter: 3-10mm
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48. Instruments cont…
• The grasping surface may be toothed or fine.
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49. Instruments cont…
• Fine grasping forceps is for atraumatic
stabilization of tissues by doing
countertraction during suturing or dissection.
• Dissecting forceps are straight or curved (Endo
dissect) with blunt tips
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50. Instruments cont…
• Toothed (claw) grasping forceps is for
liberating solid organs.
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51. Instruments cont…
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52. Instruments cont…
Bowel and lung clamps:
• Tubular structures, bowel and lung are held
with instruments designed specifically for the
same.
• E.g: Endo-Babcocks, Endo-Lung, Bowel Clamp
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53. Instruments cont…
• Laparoscopic scissors can be used for:
• Dissecting and mobilizing of tissues
• Cutting tissues and sutures
• These instruments may be straight, curved or
hooked.
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55. Instruments cont…
• Straight scissors for delicate dissection.
• Curved scissors, in general, have the same
features as for straight scissors.
–May be easier to dissect with, because the
curvature changes the viewing angle.
• Hook scissors are used to cut sutures, tough
fibrous tissue
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56. Instruments cont…
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Hook scissor

57. Instruments cont…
• Some have an electrical adapter so they can
be combined with unipolar or bipolar
electrocoagulation.
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58. Needle holders
• These are essential to perform suture and
knots.
• There are different types of needle holders:
–Handle can be straight or curved.
–Tips can be straight or curved.
• The co-axial types with a locking system are
preferred to the pistol type needle holders
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59. Ligation clip system
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60. Ergonomics
• Ergonomics is the study of the psychologic and
physical interaction between the user (e.g.,
surgeons, assistants, or nurse) and their tools
• The “relationship” between the surgeon and
their tools determines how much effort is
expended by the surgeon.
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61. Ergonomics cont…
• Simple tasks are more stressful and fatiguing
during laparoscopic surgery leading to less
physical and mental reserve.
• The proper design of the instruments and the
set up (layout) of the operating room is critical
to avoid fatigue and human errors.
• This is why ergonomics is important.
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62. The surgeon’s mental and physical reserve during
laparoscopic surgery is significantly reduced compared
to open surgery.
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63. Ergonomics cont…
• The goal is:
–Make surgeon comfortable; neck and back
maintained in upright position facing
forward.
–Proper set up for comfort and efficient
movement, and thus minimization of the
risk of musculoskeletal injuries to the
operator.
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64. Ergonomics cont…
• During laparoscopic surgery, the ability to
achieve this ideal posture is determined by:
–The height of the operating room table
–The position of the visual display (e.g.,
monitor)
–Foot pedal locations
–The selection of hand instruments
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65. Operating Table Height
• The proper adjustment of the operating table
height is very important.
• Ergonomically, angle between upper and
lower arm should be between 90° and 120°
when performing manual work.
–The operating table should be elevated or
lowered to enable the surgeon to achieve
this window.
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66. Foot Pedals
• Foot pedals are commonly used during
laparoscopic surgery to activate instruments such
as the cautery, ultrasonic shears etc.
• Pedals should be;
– Placed near the foot
– Aligned in the same direction as the instruments,
toward the target quadrant and the principal
laparoscopic monitor.
• A pedal with a built-in foot rest is preferable
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67. Vertical Positioning of Video Monitor
• The position of the video monitor affects neck
and back posture.
• The display should be placed;
– Directly in front of the surgeon
– 15°–40° below eye level for maximum comfort
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68. Key elements of the ergonomic
laparoscopic surgeon
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69. Choosing Laparoscopic Instruments
• No single design is superior to others
• Each surgeon needs to choose the design(s) that
best achieves the following goals:
–Enables the surgeon to keep both wrists in a
neutral (unbent) position
–Permits the surgeon to keep both arms at the
sides of their body
–Avoids pressure points on the hands
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70. Choosing Lap. Instruments cont…
–Allows the surgeon to apply force with a
power grip (hammer or gunstyle) hand
position
–Allows fine manipulation with a precision
grip (pencil or forceps style) hand position
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71. Choosing Lap. Instruments cont…
• The most important features to look for in
laparoscopic instruments are these:
– Handles that are smooth and broad surfaced.
Avoids pressure points and finger entrapment
– Internal mechanism that is smooth, precise, and
allows good tactile feedback from the tip of the
instrument to the handle
– Easy and intuitive access for the fingers to any
additional controls that govern shaft rotation, jaw-
locking, or electrocautery or suction activation
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72. Choosing Lap. Instruments cont…
– Sturdy insulation of the instrument shaft all the
way to the base of the jaws to avoid stray
electrocautery injury during use
– An electrocautery connector pin that keeps the
electrocautery cable out of the way of the
surgeon’s hand during use of the instrument
– Instruments that require substantial force to use
(staplers, clip appliers, heavy graspers) should
have a broad and smooth pistol-type hand that
permits the surgeon to use a power-grasp hand
position
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73. Laparoscopic Surgical Technique
• Performing laparoscopic surgery requires the
proper placement of the access ports and the
efficient and safe use of the instruments to
accomplish tissue dissection, division, sealing,
and re-approximation.
• The location of the access ports is critical because
they determine the reach and the working angle
of the instruments passed through them.
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74. Laparoscopic Surgical Technique cont..
• A manipulation angle range of 45°–75° (in the
horizontal plane, the acceptable range of
angles between the instruments inserted
through the different ports) with equal
azimuth angles (the elevation angle range in
the vertical plane) is recommended.
• Ideally, the surgeon maintains similar
elevation angles for each of the instruments
that they hold.
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75. Laparoscopic Surgical Technique cont..
• Instruments should be inserted such that at
least half of the instrument is inside the
patient.
• If the instrument is utilized while inserted less
than half of its length, excessive motion at the
shoulder will be required, which is likely to
fatigue the surgeon
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76. Laparoscopic cholecystectomy
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77. Laparoscopy in Perforated Peptic
Ulcer:
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78. Laparoscopic appendectomy
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80. Endoscopic pre-peritoneal inguinal
hernia repair (TEP)
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81. Laparoscopic ventral hernia repair
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83. single-incision laparoscopic
gastrectomy
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84. Questions?
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85. Thank you for your
attention
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