Dr Aloy J Mukherjee Best Laparoscopic Surgeon in Delhi NCR, Best Surgeon in Apollo Hospital, General Surgeon, Hernia Surgeon

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Editors
Ajay Kriplani, Parveen Bhatia,Arun Prasad,
Deepak Govil, H.P
.Garg
Comprehensive

© Copyright 2007
Indian Association of Gastro Intestinal Endo Surgeons (IAGES),
IAGES Secretariat
Global Hospital &Endosurgery Institute,
307,308, AmbikaVihar, New Delhi-110087.
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From the tiny acorn does the tall oak tree grow. A humble
small beginning can snowball into a giant new form if
its growth is pursued with dedication, commitment,
courage and passion. In 1993, a small group of 30 odd
surgeons from all over the country met in Mumbai
and set up the Indian Association of Gastrointestinal
Endo-Surgeons. The avowed purpose of the Association
was to promote and nurture the growth and spread of
Minimal Access Surgery throughout India so as to give
the obvious and profound benefits of Minimal Access
Surgery to all our people in all places. Never in their
wildest imagination could the Founder-Members have
dreamt that this surgery would spread so far, penetrate
so deep into small towns of India and reach such a high
standard of performance as to place India in the forefront
of laparoscopic endeavour. IAGES members from all over
India, right from Guwahati, Srinagar, Jammu to Salem,
Coimbatore, Nagercoil and all over have spread and
advanced MAS in 14 short years over the country and
added voluminously to the world literature and teaching
methodology on this subject.
Since its inception, IAGES has set the bench mark of
democratic functioning—biannual election to Office by
secret postal ballot, involvement of the entire country in
its active leadership, stepping back completely of senior
membersto hand overthe running of the Association to
the next group of younger, more energetic and dynamic
members. The strength of the Association has received
world recognition both by the stature of the Faculty at
its numerous Conferences, as also by being unanimously
accepted as a Member Society of the International
Federation of Societies of Endoscopic Surgeons (IFSES).
Having spread MAS all over the country, the entire
current Executive Committee with Dr. Kuldip Singh
as President and Dr. Parveen Bhatia as Secretary have
realised the value and wisdom of ensuring that all
surgeons doing all laparoscopic surgery have, each one
of them, attained a certain level of skill and knowledge to
ensure the safety and well-being of every single patient.
This is the raison d’être of this Fellowship Course
with Dr. Ajay Kriplani as its Convenor. The purpose
of the Course is not to claim that IAGES is a superior,
regulatory body, not to drum up Membership, not to
offer a piece of paper, at a price, with a few signatures
on it—the sole intent of this Fellowship Course is to
further the primary purpose of the Founder Members by
spreading MAS to the smallest moffisul and ensuring a
high uniform quality to our surgery both by teaching as
also by personal example, stressing not just the technical
advances but also the humane aspects of this surgery.
Dr.T
ehemton E.Udwadia
Founder President – IAGES
Foreword

In the past decade, since the inception of minimal access
surgery, there have been major advances in this field. The
excitement that general surgeons first experienced with
Laparoscopic Cholecystectomy has been transplanted
into a variety of other specialties, all of which have
found promising applications for minimal access surgery.
Almost all the surgeries are being done with the minimal
invasive technique, seeing the obvious advantages it
provides to the patients. Basic principals of the surgery
remain the same whereas the approach has been changed.
To start with it was through experience and existing skills
that surgeons had to utilize to master this technique.
As we see now that minimal access surgery in itself
has become a full specialty and with all the major
changes in the legislation and patient expectations, more
and more stress is being paid on the mentor training in
the field of minimal access surgery. The specialty courses
have already been started in many institutes across the
country but even then, it needs continuous updating
of the technique and skills to progress in the field and
provide the best possible patient care.
This series has been compiled keeping in view the
common procedures and the common complications
that occur during these procedures. This book will go
a long way in guiding the surgeons to improve upon
the technique, avoid the complications and provide the
excellent results to their patients.
Dr Kuldip Singh,
President, IAGES
Foreword

The thought to bring out this book was
conceived while planning the first Fellowship
Course of the IAGES at New Delhi. It was
decided to request all the speakers to also
write a chapter. The aim was to give detailed
description about the topic which cannot be
covered during the limited time of the lecture.
Despite the short time, the authors responded
promptly and have put in their best efforts to
write about their specialised field of interests.
The book includes 27 chapters ranging from
basic to advanced laparoscopic procedures. It
provides comprehensive theoretical as well as
practical aspects of situations specially faced by
the Indian surgeons.
The articles have more than 450 endoscopic
and graphic illustrations.
The authors, Minimal Access Surgeons of
eminence with specialised interests in the areas
have significantly contributed to the development
of Laparoscopic Surgery in India.
The Comprehensive Laparoscopic Surgery is
intended for the young and the experienced
Laparoscopic Surgeons alike. This is only the
beginning with a vision to transform into a
textbook.
Editors
Preface

We are grateful to the President, Dr. Kuldip Singh and
Executive Committee members of Indian Association of
Gastro Intestinal Endo-Surgeons (IAGES) for entrusting
us the responsibility of conducting the 1st Fellowship
Course (FIAGES) from 29th March to 1st April, 2007
at New Delhi.
The response of all the speakers and delegates for the
course has encouraged us to compile the work into a book
form ‘Comprehensive Laparoscopic Surgery’. We are
thankful to all the authors who responded to our request
of sending the complete text at such a short notice.
The book ComprehensiveLaparoscopicSurgery would not
have seen the light of the day without the untiring efforts
of Drs. Aloy Jyoti Mukherjee, Shyam Sunder Pachisia,
Sushank Rastogi, Hari S. Sidhu, Daipayan Ghosh and
Tarun Jain. We thank Mr. Arun Kumar and Mr. Amit
Mattoo for their secretarial assistance.
Mr. Manuj Bajaj and his team members Manoj Malik,
Izzur Rahman, Rajesh Kumar, Ritesh Malhotra have
done an excellent job in designing the book.
We would definitely like to give complements to
Mr. Bhupender Sagar and his team at Sagar Printers
especially Mr. Chander Kant Pant.
AjayKriplani,Parveen Bhatia,Arun Prasad,
Deepak Govil,H.P.Garg
Acknowledgements

Contents
Foreword by Dr. T
. E. Udwadia
Foreword by Dr. Kuldip Singh
Preface
Acknowledgements
List of Contributors
C H APt e R 1.......................................................................................................................1
Landmark historic events, Endovision system:
Maintenance and trouble shooting
G. R.Verma, S.Thiagarajan
C H APt e R 2.......................................................................................................................9
Laparoscopic Hand Instruments, Accessories and Ergonomics
Amitabh Goel
C H A P te R 3
.......................................................................................................................20
Sterilization and Maintenance of Instruments & Equipment
Deepraj S. Bhandarkar, Avinash N. Katara
C H A P te R 4
.......................................................................................................................26
Energy sources in Laparoscopy and their optimal use
Rajeev Sinha
C H A P te R 5
.......................................................................................................................40
Endosuturing and Tissue Approximation in Laparoscopic Surgery
Rajesh Khullar
C H A P te R 6
.......................................................................................................................52

C H A P te R 7 .......................................................................................................................57
Peritoneal Access and Creation of Pneumoperitoneum for
Laparoscopic Surgery
Zameer Pasha
C H A P te R 8 .......................................................................................................................64
Operative Technique for Laparoscopic Cholecystectomy
Tehemton E. Udwadia
C H A P te R 9 .......................................................................................................................77
Difficult Laparoscopic Cholecystectomy
Kuldip Singh, Ashish Ohri
C H A P te R 10 .....................................................................................................................81
How to predict difficult Laparoscopic Cholecystectomy
and when to convert?
Subhash Khanna
C H A P te R 11 .....................................................................................................................90
Detection and Management of CBD Stones in the
Era of Laparoscopic Cholecystectomy
Jyotsna S. Kulkarni
C H A P te R 12 .....................................................................................................................95
Management of Post-operative Complications after
Laparoscopy Cholecystectomy
B. Krishna Rau
C H A P te R 13
.....................................................................................................................100
Understanding Endoscopic Anatomy of Inguinal Region
Parveen Bhatia
C H A P te R 14
.....................................................................................................................119
Laparoscopic T
rans Abdominal Pre-Peritoneal (TAPP) Repair
of Inguinal Hernia
A.K. Kriplani, Shyam S. Pachisia, Daipayan Ghosh
C H A P te R 15
.....................................................................................................................131
Laparoscopic Inguinal Hernia Repair—TEP Technique
Pradeep K. Chowbey
C H A P te R 16
.....................................................................................................................135
Laparoscopic Appendicectomy
M. G. Bhat
C H A P te R 17
.....................................................................................................................140

C H A P te R 18
.....................................................................................................................149
Laparoscopy in Gastric Outlet Obstruction due to Peptic Ulcer Disease
K. Ravindranath
C H A P te R 19
.....................................................................................................................155
Laparoscopic Gastrectomy
K. Ravindranath
C H A P te R 20
.....................................................................................................................159
Laparoscopic Surgery for Colon and Rectal Cancer
Deep Goel, Naresh Garg, V. K. Malik
C H A P te R 21
.....................................................................................................................163
Laparoscopic Splenectomy
Abhay N. Dalvi
C H A P te R 22
.....................................................................................................................169
Laparoscopic Urological Surgery
Rajesh Ahlawat
C H A P te R 23
.....................................................................................................................178
Laparoscopic Adrenalectomy
A.K. Kriplani, Hari S. Sidhu
C H A P te R 24
.....................................................................................................................186
Laparoscopic Gynaecological Surgery for General Surgeon
Pradeep Kumar Garg, Alka Kriplani
C H A P te R 25
.....................................................................................................................198
Laparoscopic Adjustable Gastric Banding for Morbid Obesity
A. K. Kriplani, Aloy J. Mukherjee, Daipayan Ghosh
C H A P te R 26
.....................................................................................................................212
Laparoscopic Roux-en-Y Gastric Bypass
M. Lakdawala, S. Goel, V. Lotwala
C H A P te R 27
.....................................................................................................................221
Video Assisted Thoracic Surgery (VATS)
Arun Prasad

Aloy Jyoti Mukherjee
MS,
Attending Consultant,
Department of Laparoscopic and GI Surgery,
Indraprastha Apollo Hospitals,
SaritaVihar,New Delhi-110076.
dr.aloy@yahoo.com
Ajay Kumar Kriplani
MS,
Senior Consultant,
Division ofBariatricSurgery,
kriplani@laparoscopy.inkriplani@ndf.vsnl.in
www.obesitysurgeries.com
Avinash N.Katara
MS, DNB, MNAMS, MRCS (Ed), Fellow-MIS (Singapore)
Minimal Access, Obesity & General Surgeon,
Department ofMinimal Access Surgery,
P.D.Hinduja National Hospital &Research Centre,
Mumbai-400016,Maharashtra.
avinashkatara@gmail.com
Ashish Ohri
MS,
Senior Resident,
Department ofSurgery,
Dayanand Medical College &Hospital,
Ludhiana, Punjab.
Abhay N.Dalvi
MS,
Consultant GI & Laparoscopic Surgeon,
Unit Chief, General Surgery,
AssociateConsultant Surgical Gastroenterology,
Seth G.S.Medical College &KEM Hospital,
Mumbai,Maharashtra.
abhaydalvi@hotmail.com
Alka Kriplani
M.D, FAMS, FICOG, FICMCH, FIMSA,
Professor, Department of Obstretics & Gynaecology,
All India Institute of Medical Sciences,
AnsariNagar(E),New Delhi-110029
kriplanialka@hotmail.com
Amitabh Goel
MS., FAIS, FICS,
Senior Consultant & Incharge,
Minimal Access Surgery,
ChoithramHospital &Research Centre,
Indore–452014, Madhya Pradesh.
goelamitabh@hotmail.com
Arun Prasad
MS, FRCS, FRCS (Ed),
Senior Consultant Minimal Access Surgeon,
SaritaVihar,New Delhi–110076.
surgerytimes@gmail.com
www.surgerytimes.com
List of Contributors

B.Krishna Rau
MS, FRCS (Eng and Ed), FRCS (Thailand),
FIAMS (Hon), FACG, FICS, FIGSC,
Professor Emeritus, Dr. MGR Medical University, Chennai,
Consultant Surgeon,Cancer Institute,
Chennai,Tamil Nadu.
bkr@vsnl.com
Deep Goel
DNB, FRCS,
Consultant, Minimal Invasive & Colorectal Surgery,
Sir Ganga RamHospital,
New Delhi–110060.
goel_ deep@hotmail.com
Deepak Govil
MS, PhD (GI Surgery),
Senior Consultant, Laparoscopic & Surgical Gastroenterologist,
Department ofSurgical Gastroenterology,
deepakgovil@rediffmail.com
Deepraj S.Bhandarkar
MS, FRCS, FICS, FAIS, FACG,
Consultant, Minimal Access Surgeon,
Department ofMinimal Access Surgery,
P.D Hinduja National Hospital &Research Centre,
Mumbai-400016,Maharashtra.
deeprajbhandarkar@hotmail.com
www.laparoscopyindia.com
Daipayan Ghosh
DNB Student,
daipayan.g@gmail.com
G.R.Verma
MS, MNAMS, FICS, FRCS,
Professor of Surgery,
Post Graduate Institute of Medical Research,
Chandigarh–160023,Punjab.
grverma2004@yahoo.co.uk
H.P.Garg
MS,
Senior Consultant, General & Laparoscopic Surgeon,
Department ofSurgery,
drhpgarg@rediffmail.com
Hari S.Sidhu
MS,
SeniorRegistrar,
Jyotsna Kulkarni
MS., FRCS,
Consultant, Minimal Access Surgery,
Kulkarni Endo-Surgery Institute & Reconstructive Urology Centre,
Pune– 411038,Maharashtra.
sanjyo@hotmail.com
www.kulkarniendosurgery.com
K Ravindranath
MS, FRCS (Ed), FCS (Glasgow),
Minimal Access Surgeon & Surgical Gastroenterologist,
Managing Director, Global Hospitals, Hyderabad–
500004. Andhra Pradesh.
hyd2_ drkravi@sancharnet.com drkravindranath@globalhospital.net
Kuldip Singh
MS, FRCS,
Professor of Surgery,
Dayanand Medical College &Hospital, Ludhiana–141002, Punjab.
drkkanda@rediffmail.com drks508@yahoo.co.in
Muffazal Lakdawala
MS,
Chief, Minimal Access Surgery,
SaifeeHospital &Chief BariatricSurgery,
Dr.L.HHeeranandani Hospital,
Mumbai– 400008,Maharashtra.
muffidoc@gmail.com
www.obesenomore.com
M. G.Bhat
MS, FRCS (England), FRCS (Ed), FICS,
DMIRCSED (Infomatics), DMLE (Law)
Consultant Gastroenterology & Laparoscopy,
Wockhardt Hospital,Bangalore–560025,Karnataka.
drmgbhat@gmail.com

Naresh Garg
MS,
Consultant Surgeon,
New Delhi–110060.
Parveen Bhatia
MS, FICS,
Medical Director & Consultant Laparoscopic Surgeon,
Global Hospital &Endosurgery Instutite,
New Delhi - 110087
bhatiaglobal@yahoo.co.in
www.bhatiaglobalhospital.com
Pradeep Chowbey
MS, MNAMS, FIMSA, FAIS, FICS, FACS,
Chairman Minimal Access & Bariatric Surgery Centre,
Sir Ganga Ram Hospital, New Delhi–110060.
chowbey1@vsnl.com chowbey@del2.vsnl.net.in
www.chowbey.com
Pradeep Kumar Garg
MD,
Assistant Professor,
Department of Obstretics &Gynaecology,
All India Institute of Medical Sciences,
New Delhi–110029.
pkgarg _ in2004@yahoo.com
Rajeev Sinha
MS,
Professor & Head,Department of Surgery,
M.L.B Medical College,
Jhansi,Madhya Pradesh.
sinha _ rga@yahoo.co.in
www.sinharga.com
RajeshAhlawat
MS, MCh (Urology),
Director, Urology and Renal Transplantation,
Fortis Hospital,Noida.
Fortis Hospital, Vasant Vihar, New Delhi.
rajesh.ahlawat@gmail.com
Rajesh Khullar
MS, FICS,
Senior Consultant, Minimal Access & Bariatric Surgery Centre,
New Delhi–110060.
drrajeshkhullar@yahoo.com
www.sgrh.com
S.Thiagarajan
MS,
Department of Surgery,
Post Graduate Institute of Medical Research,
Chandigarh–160023,Punjab.
Subhash Khanna
MS, FICS,
Swagat Endolaparoscopic Surgical Research Institute,
Guwahati,Assam.
subhashkhanna@sify.com
Shyam Sunder Pachisia
MS,
Junior Consultant,
Indraprastha Apollo Hospitals
SaritaVihar,New Delhi-110076
drsspachisia@gmail.com
S.Goel
MD,
Consultant Anaesthesist,
Dr.L.H.Heeranandani Hospital,
T
ehemton Erach Udwadia
MS, FCPS, FRCS(Eng), FACS, FICS(Hon), FAMS, FARSI(Hon),
Emeritus Professor of Surgery,
Grant Medical College & J.J.Hospital,
Consultant Surgeon, Head Department of M.A.S.
P.D.Hinduja National Hospital,
Consultant Surgeon, Parsee General Hospital,
Breach Candy Hospital, Mumbai–400001. Maharashtra.
pnd@vsnl.net
V.Muralidhar
MD,
Department of Anaesthesiology & Critical Care,
SaritaVihar,New Delhi–110076.
murali22 _ 99@yahoo.com.sg
murali2v@gmail.com
V.Venkatesh
MS,
Consultant Surgeon,
V.G.Hospital,
Coimbatore– 641034.
vghospital@eth.net

V.K Malik
MS,
Senior Consultant Surgeon,
Department ofGeneral Surgery
New Delhi–110060.
svmalik@yahoo.com
V.Lotwala
M.S,
Consultant Surgeon,
Dr.L.H Heeranandani Hospital,
Zameer Pasha
MS, FICS, FAIS, FAIMS, Dip. MAS,
Chairman, Shahnawaz Hospital,
Trichy–620018,
Tamil Nadu.
drzameer2k@sify.com drzamir@yahoo.com

As we enter in the 21st century, we are witnessing dawn
of a new era in which closed body operating procedures
are more often being performed through minimal access.
T his development is the result of vision and work of many
dedicated individuals. They include early pioneers of
endoscopy who planted the seed and finally the modern
pioneers who pushed and expanded these frontiers to
give rise the birth of modern laparoscopy. Therapeutic
laparoscopic surgery was introduced into the surgical
practice recently and within a short span of time, it has
become established as gold standard for the treatment of
chronic cholelithiasis and many advanced laparoscopic
procedures can be performed safely. Laparoscopic
surgery, what we witness today, is the culmination of
over a century of painstaking efforts of the number of
pioneers in the fields of optics, instrumentation and video
laparoscopic camera.
Few advances in medicine occur in isolation. The
innate human curiosity to peer inside the body cavities
can be traced back to ancient times. However, due to
primitive technology and crude instruments, many of
these ambitions were not realized. It is probably safe to
say that first laparoscopy would not have been performed
had it not been for the efforts of many physicians in
19th century to develop endoscope. The device in Fig.1
developed by Theodore Stein in mid 1880 contains all
the elements of the current endoscopic documentation
system. There was a crude endoscope and a high intensity
light source. Illumination was created by continuously
feeding a magnesium wire into an ignition chamber using
a clockwise mechanism. Light from this combustion was
reflected into the tube using a mirror. Finally the image
was focused on to a photographic plate through coupling
optics.
Fig. 1: Early endoscopic devicebyTheodore Stein
The word laparoscopy is derived from a Greek word
lapara, meaning “the soft part of the body between
ribs and hip, flank, loin” and skopein, which means “to
look at or survey”. First documented laparoscopy was
undertaken in 1901 by Damitri Oksarovich Ott (1858-
1929) of St. Petersburg, Russia, using gynecologic
head mirror, an external light source and a speculum
to perform the procedure. He termed the procedure
“Ventroscopy” (1). In 1902, George Kelling (Fig.2) of
Dresden, Germany outlined the technique of visualizing
the peritoneal cavityand it’s contents in adog byinserting
Landmark historic events,
endovision system: Maintenance
and trouble shooting
G.R.Verma, S.Thiagarajan
1

2 Landmark historic events, Endovision system: Maintenance & trouble shooting
Fig. 2: GeorgeKelling of Dresden,Germany
a cystoscope inserted through a trocar and creating
pneumoperitoneum with filtered air. At the same time,
a Swedish surgeon, Jacobaeus (Fig. 3) in 1910, coined the
term “ laparoscopy” (2) which has subsequently become
the accepted terminology used to describe almost all
varieties of this form of intervention. He published his
experience on the technique of laparoscopy in humans
for the first time. The next technological advance
in laparoscopic technology was provided in 1920 by
Benzamin Orndoff (3) who developed a sharp pyramidal
point on laparoscopic trocar to facilitate puncture.
Professor Kalk (Fig. 4) from Germany pioneered
the use of laparoscopy for disorders of liver and biliary
tract. He introduced the oblique viewing optics from
longitudinal axis permitting better inspection of organs,
as the image could be changed by altering the viewing
direction of the optics such that the lens moved around
the object. In 1929 he was the first to describe dual
puncture technique. The use of second puncture opened
the way for the development of operative laparoscopy. T he
next significant development in laparoscopic technology
occurred in 1938 when Hungarian surgeon, Janos Varess
(Fig. 5) described a spring loaded needle with an inner
stylet that automatically converted the sharp cutting
edge to a rounded end by incorporating a sidehole (4)
. for creation of pneumoperitoneum. He was the chief
physician at the Komitat hospital in Hungary. The
needle had initially been used to create a pneumothorax
to treat tuberculosis. The first description of operation
performed under laparoscopic vision came from Fervers
in 1933. He performed laparoscopic adhesiolysis with
biopsy instruments. He used oxygen as distending
medium and experienced “great concern” at the audible
explosion and flashes of light produced by electrocautery
within the abdominal cavity. He recommended changing
to carbon di oxide as insufflating gas for creating
pneumoperitoneum.
Kurt Semm, a gynecologist (Fig.6), played the vital
role in the development of operative laparoscopy. It was
Semm who developed the automatic insufflating device
that monitored intra abdominal pressure and gas flow in
1963 (5). Prior to this, air was introduced by most workers
into peritoneal cavity with the help of a syringe. Semm
Fig. 3: HansChristian Jacobaeus of Stockholm, Sweden Fig 4: Professor Kalk,promoterof theoblique(45 degrees)lenssystem

Comprehensive Laparoscopic Surgery 3
Fig. 5: JanosVaress,HungarianSurgeon
designed the pre tied suture loop (Roeder knot) to allow
adequate haemostasis. He also developed a high volume
suction/irrigation apparatus with design modifications
to prevent tube clogging. Many more instruments i.e.
needle holder, micro scissors, clip applier, morcellator
were conceptualized, created and first utilized at Kiel
University by him. He also created pelvi trainer, designed
to teach surgeons the video eye hand coordination
and suture tying techniques He was the first person
to perform laparoscopic appendectomy in 1982 and
soon thereafter, using his instruments, Erich Muhe, a
surgeon from Boblingen performed first laparoscopic
cholecystectomy in 1985. Unfortunately his technical
presentation to Congress of German Surgical Society
met with considerable resistance. The surgery was later
performed with the help- of video camera in France by
Phillipe Mouret (Fig. 7) in 1987.
No one has contributed more widely to the
development and use of laparoscopy in general surgery
than George Berci (6) in Los Angeles, both in the design
of instrumentation and identifying clinical situations in
surgical practice where laparoscopy would materially
benefitmanagementof thepatient. He pioneeredthe useof
laparoscopy for the management of diagnostic dilemmas,
especially in emergency situations, and was instrumental
in the development of laparoscopy for trauma.
ENDOVISION SYSTEM FOR LAPAROSCOPY
Video camera
It is safe to say that the development of laparoscopic
surgery would not have been possible without the video
laparoscopic camera in 1986.This instrument allowed all
members of the operating team to view operative field
simultaneously, permitting the type of coordinating
movements required for complex operative procedures.
Prior to that operative laparoscopy was restricted to
the individual directing the operative procedure and
participation by other members of the surgical team was
limited.
The foundation of the laparoscopic camera is the
solid state chip sensor. The most commonly used sensor
is charged coupled device (CCD). The C C D is composed
of small pieces of silicone called pixels, which are
arranged in rows and columns and are sensitive to light.
When light strikes a pixel, the silicon emits electricity,
which is transmitted to the monitor. The electronic
signals are then reconstructed on the monitor to give the
video image. The resolution of the C C D is determined
by number of the pixels on the sensor. The resolution
Fig 6: Gynecologist KurtSemmof Kiel,Germany
Fig. 7: PhillipeMouret,France

is defined as the number of vertical lines that can be
discriminated as separate in three quarters of the width
of the monitor screen. The laparoscopic camera requires
at least 300 lines of resolution to provide an adequate
image. Now a day’s triple chip camera are available, with
each chip devoted to only one color of the spectrum.
Since the major spectrum is derived from three colors
i.e. red, green and blue, modern three chip camera is able
to reconstruct the image consisted of these three primary
colors and provide excellent resolution and color but they
are significantly more expensive.
Light source & transmission
One of the primary problems in the development of video
laparoscopy was the insufficient light. A typical light
source consisted of a lamp “ bulb”, heat filter, a condensing
lens and manual or automatic intensity controlled circuit.
Lamp or bulb is the most important part of the light
source. The Quality of light depends on the lamp used.
Several Modern types of light sources are currently
available on the market. These light sources mainly differ
on the type of bulb used. Four types of lamp are used
more recently. 1. Quartz halogen. 2. Incandescent bulbs
3. Metal halide vapor arc lamp 4. Xenon.
A normal light source (alight bulb) uses approximately
2 % in light and 98 % in heat. This heat is mainly due
to the infrared spectrum of light and due to obstruction
in the pathway of light. If Infrared will travel through
the light cable than the cable will be intolerably hot. A
heat filter is introduced to filter this infrared to travel in
fiber optic cable. A cool light source lowers this ratio by
creating more light, but does not reduce the heat produced
to zero. The purpose of condensing lens is to converge
the light emitted by lamp to the area of light cable input.
In most of the light source it is used for increasing the
light intensity per square cm of area.
Most common type of light source was halogen bulb.
It is highly efficient crisp light source with excellent color
rendering. The electrodes are made up of Tungsten.
They utilize halogen gas that allows the bulb to burn
more intensely without sacrificing its life. They have
average life of 2000 hours. These lamps are cheap and
can be used for laparoscopic surgery if low budget set up
is required. However, they lack in providing the natural
white light color. Metal halide vapor arc lamp is a mix
of compounds, (mostly salts of rare earths and halides as
well as mercury which provided the conduction path) is
carefullychosento produceanoutputwhichapproximates
to “white light” as perceived by the human eye. There are
two types of metal halide lamp, iron halide and gallium
iodide lamp. Although the light generated was white but
not exactly the replica of natural light. This problem has
largely been eliminated with the introduction of high
intensity Xenon light source. Xenon lamps consist of a
spherical or ellipsoidal envelope made of quartz glass,
which can withstand high thermal loads and high internal
pressure. For ultimate image quality, only the highest-
grade clear fused silica quartz is used. It is typically
doped, although not visible to the human eye, to absorb
harmful U V radiation generated during operation. The
color temperature of Xenon lamp is 6000-6400 K. The
operating pressures are tens of atmospheres at times, with
surface temperatures exceeding 600 degrees C. The light
emitted by xenon lamp is slightly bluish and more natural
compared to halogen lamp. However, most of the cameras
at present analyze and compensate these variations by
means of automatic equalization of whites (2100 K to
10000 K), which allows the same image to be obtained
with both light sources. A proper white balancing before
start of the operation is a very good practice for obtaining
a natural color. The white light is composed of the equal
proportion of Red, Blue and Green Color and at the time
of white balancing the camera sets its digital coding for
these primary colors to equal proportion assuming that
the target is white. And if at the time of white balancing
the telescope is not seeing a perfectly white object then
the setup of the camera will be very bad and the color
perception will be very poor.
Prior to the introduction of fiber optic cables, the
light source was incorporated in the laparoscope itself
making it heavier, and cumbersome. In 1954 a major
breakthrough in technology occurred in the development
of fiber optic cables. The principle of fiber optic cable
was based on the total internal reflection of light. Light
could be transmitted through a curved glass rod due to
multiple total internal reflections at the walls of the rod.
Light would enter at one end of the fiber and emerge at
the other end after numerous internal reflections with
virtually all of its strength. Now a days two types of
light cable are available in market. 1. Fiber Optic cable 2.
Liquid crystal G el cable. T he optical cablesare made up of
a bundle of optical fiber glass thread swaged at both ends.
They have a very high quality of optical transmission,
but are fragile. In fact, some of the fibers may break due
to repeated use. The broken fibers are seen as black spots
when cable is viewed against day light. The gel cables
are made up of a sheath that is filled with a clear optical

gel. (Liquid crystal) and swaged at both ends by quartz.
Theoretically they are capable of transmitting 30% more
light than optic fibers. Due to more light and better color
temperature transmission this cable is recommended
in those circumstances where documentation (movie,
photography or TV) is performed. They pose three
problems 1. The quartz swaging at the ends is extremely
fragile, especially when the cable is hot. The slightest
shock, on a bench for example, can cause the quartz end
to crack and thus cause a loss in the transmission of the
light 2. These cables transmit more heat than optical fiber
cables 3. They are more rigid due to metal sheath, which
makes them more difficult to maintain.
Of the most crucial invention in operative laparoscopy
was by British Physicist, Harold Hopkins in 1952, who
developed the idea of the rod lens system. Prior to this
development, endoscopes were constructed on an optical
system that comprised relay and field lenses made from
glass with long intervening air spaces. In Hopkins system,
the roles of glass and air are interchanged such that the
optical system consists of air lenses and long glass air
spaces. As the refractive index is now predominantly that
of glass, the light transmission capacity of the endoscopes
isdoubled. A second advantage of H opkinsrod lenssystem
relates to the “larger radius of clear aperture” available at
the viewing optic that was not possible with conventional
endoscopes.
MAINTENANCE
Light Cable: Handle it carefully and do not twist it. After
the completion of operation, cable should preferably be
disconnected from the endoscope and then from light
source. Avoid direct fall of light on eyes. The retina can get
damaged. The cable should be periodically cleaned with
cotton swab moistened with alcohol. The outer covering
of the cable should be cleaned with mild detergent or
disinfectant. The fiber optic cable should not be placed
near the patient when it is connected to illuminated light
source. The heat generated may cause burn
Instruments
Meticulous care should be taken in mechanically cleaning
all the parts of all laparoscopic instruments. The handles
are un-screwed, inserters taken out and the hollow sheath
is cleaned with running water or syringe. Instruments are
wiped dry gently and lubricated with silicone oil. These
are the vital steps before sterilization or disinfection of
laparoscopic instruments. All metal instruments or part
that can undergo sterilization using a steam autoclave
should be handled in this manner. Suction/ Irrigation
tubes are thoroughly cleaned with running tap water
before autoclaving them.
Telescope and Camera
The telescope eye piece, light cable slot and its patient
end must be cleaned with warm water and the patient end,
additionally with camera cleaner liquid. The ends of the
telescope are sensitive to heat; hence it should be sterilized
with chemical sterilizer. Laparoscopic camera will be
damaged by heat as well as repeated exposure to chemical
germicides. More over the irregular configuration of the
surface of camera makes the disinfection difficult and
unpredictable. Therefore camera are best treated with
the use of barrier such as sterile plastic/ cotton sleeve to
avoid contamination of operating field. They are most
expensive parts of equipment, hence must be handled
with utmost care. Avoid crumpling of its lead and never
use alcohol/ spirit to clean the camera head. Instead use
camera head cleaner supplied by company or it can be
simply cleaned with moist warm cotton.
Sterilization
It is defined as complete elimination/ destruction of all
forms of microbial life. It can be achieved with steam,
gas or chemical sterilants. Disinfection which is a relative
term means elimination of many or all pathogenic
organisms except bacterial spores. It is divided into three
levels, high, intermediate and low. High level disinfection
eliminates all organisms with exception of large number
of bacterial spores. Intermediate level disinfection
destroys all organisms except spores, most bacteria and
some fungi. Low level of disinfection can destroy most
bacteria, some viruses and some fungi.
High level disinfection is accomplished by 2%
Glutaraldehyde solution, a most popular chemical sterilant
used for high level disinfection of laparoscopic equipments.
T he minimum recommended exposure time is10 minutes,
although some workers prefer and recommend for 20
minutes. It can sterilize the instruments only after ten
hours of exposure. The life of the solution is generally 20-
25 days. The potency and use life of the solution is
determined more by use pattern and not strictly by time.
The heavy use and inadvertent dilution or contamination
will require early change of sterilant.
It should be mentioned that no addition to described
protocol is required to deal with HIV or hepatitis-B

Table 1
Problem Cause Solution
1. Poor
insufflation/loss of
pneumoperitoneum.
CO, tank empty Change tank
Open accessory port stopcock(s) Inspect all accessory ports
close stopcock(s)
Leak in sealing cap or
stopcock. Excessive
suctioning
Change cap or cannula
Allow abdomen to re-insufflate
Instrument cleaning channel
screw cap missing
Replace screw cap
Loose connection of insufflator
tubing at source or at port
Tighten connection
Hasson stay sutures loose. Replace or secure sutures
2. Excessive pressure
required for
insufflation (initial or
subsequent)
Veress needle or cannula tip not
in free peritoneal cavity
Reinsert needle or cannula
Occlusion of tubing (kinking,
table wheel, inadequate size
tubing, etc.)
Inspect full length of tubing,
replace with proper size as
necessary
Port stopcock turned off Assure stopcock is opened
Patient is “light” More muscle relaxant
3. Inadequate lighting
(partial/ complete
loss)
Loose connection at source or at
scope
Adjust connector
Light is on “manual minimum” Go to “automatic”
Bulb is burned out Replace bulb
Fiber optics are damaged Replace light cable
Automatic iris adjusting to
bright reflection from
instrument
Reposition instruments, or switch to
“manual”
Monitor brightness turned down Readjust setting
4. Lighting too bright Light is on “manual-maximum” Go to “automatic”
“Boost” on light source activated. Deactivate “boost”
Monitor brightness turned up Readjust setting
5. No picture on monitor(s) Camera control unit or other
components (VCR, printer, light
source, monitor) not on
Make sure all power sources
are plugged in and turned
on
Cable connector between camera
control unit and/or monitors not
attached properly
Cable should run from “video out”
on camera control unit to “video
in” on primary monitor; use
compatible cables for camera unit
and light source
Cable should run from “video
out” on primary monitor to

Problem Cause Solution
6. Poor quality picture.
a. Fogging, haze
Condensation on lens of cold
scope entering warm
abdomen.
Gently wipe lens on viscera; use anti-fog
solution, or warm water, gently
wiping on liver or uterine surface
is preferable
Condensation on scope eyepiece,
camera lens, coupler lens
Detach camera from scope (or
camera from coupler), inspect
and clean lens as needed
b. Flickering
electrical
interference
Moisture in camera cable
connecting plug
Use compressed air to dry out
moisture (don’t use cotton-tip
applicators on multi prong plug)
Poor cable shielding Replace video cable between
monitors
Insecure connection of video
cable between monitors
Reattach video cable at each
monitor
c. Blurring, distortion Incorrect focus Adjust camera focus ring
Cracked lens, internal moisture Inspect scope and camera,
replace as needed
7. Inadequate suction/
irrigation
Occlusion of tubing
(kinking, blood clot,
etc.)
Inspect full length of tubing;
if necessary detach from
instrument and flush tubing
with sterile saline
Occlusion of valves in suction/irrigator
device
Detach tubing, flush device
with sterile saline
Not attached to wall suction Inspect and secure suction
canister connectors, wall
source connector
Irrigation fluid
container not
pressurized
Inspect compressed gas
source, connector,
pressure dial setting
8.
Absent/ina
dequate
cauterization
Patient not grounded properly Assure adequate patient
grounding pad contact, and
pad cable
electro-surgical unit connection
Connection between
electro-surgical unit and
pencil not secure
Inspect both connecting points
Foot pedal or hand switch
not connected to
electrosurgical unit
Make connection

contaminated equipments. Both hepatitis and HIV virus
are inactivated many physical and chemical processes
much less potent than high level disinfection.
A new sterilization process, marketed as STERIS is
also available. Its active agent is per acetic acid, generally
considered to be a stronger germicide that has very
little harmful effects on optical instruments. It has the
advantage of being a closed system and is not subject to
various factors responsible for bringing down the efficacy
of chemical germicide.
TROUBLE SHOOTING
Laparoscopic procedures are inherently complex. Many
things can go wrong. The surgeon must be sufficiently
familiar with the equipment to troubleshoot and solve
problems. Table 1 gives an outline of the common
problems, their cause, and suggested solutions.
In conclusion, I would say that the pace of development
of diagnostic laparoscopy which was hitherto slow
but steady over the last century has entered into an
exciting era of laparoscopic surgery with invention of
miniaturized video endoscopes, quality light source and
successful performance of laparoscopic cholecystectomy.
Credit goes to many scientists who steadfastly continued
their efforts to bring this science to the current state
of art. The laparoscopic instruments are long, fine and
insulated; hence, they are more vulnerable to wear and
tear. Gentle handling and thorough mechanical cleaning
& lubrication prior to sterilization/ disinfection will
increase their life and efficiency. A laparoscopic surgeon
should have knowledge of instrument functioning, basic
knowledge of supportive equipments and able to manage
the trouble shooting.
REFERENCES
1. Ott D. Illumination of the abdomen (Ventroscopia) JAkush Zhnesk
Boliez 1901; 15: 1045-49.
2. Jacobaeus HC. Ueber die moglichkeit die zystoskopie bei
untersuchung serosar hohlungen anzuwenden. Munich ,Med
Wochenschr. 1910; 57: 2090-92.
3. Orndoff BH. The peritoneoscope in diagnosis of diseases of the
abdomen. JRadiol 1920; 1: 307.
4. Veress J. Neues instrument zur Ausfuhrung von Brust-order
Bauchpunktionenund Pneumothorax behandlung. Dtsch Med
Wochenshr. 1938; 41: 1480-81.
5. SemmK.History,InOperativeGynecologicEndoscopy,J.S.Sanfilippo,
R.L.Levine,editors, New York, Springer- Verlag,1989.
6. Berci G, Shore JM, Panish J,Morgenstern L. Evaluation of a new
peritoneoscope as a diagnostic aid to the surgeon. Ann Surg
1977; 135: 32-35.
7. Airan MC. Equipment set up and trouble shooting. in The SAGES
manual, fundamentals of laparoscopy and GI endoscopy, Caro
EH, Scott C, editors, Springer. New York 2003; 1-11.

Laparoscopic procedures are inherently complex. Due
to the complex modern technology, many things can
go wrong. Equipment and instrumentation have a much
greater impact and importance in laparoscopic surgery.
This is a fact that visualization and tactile exploration
of the operative field is always only indirectly achieved
through optical systems and instruments. The surgeon
must be sufficiently familiar with the equipment to use it,
troubleshoot and solve the inherent problems.
I. IMAGING SYSTEM
Imaging system includes the Laparoscope, Light source,
Light cable, Camera, and Monitor.
A. Laparoscopes
Laparoscopes are either rigid or fibre optics (fig. 1).
Commonly used are rigid ones, like 0°, 30°,3mm, 5mm, and
10mm. The 30° angled scopes can be rotated and can see.
down as well look up the anterior abdominal wall and side
ways. The scope is attached with light cable and the distal
tip is inspected for fibre bundle transmission. If the fibre
damageis 25% or morethen the scope must be replaced.
B. Light Source
The new light source (fig. 2) such as 250 watt halogen
lamp has been provided with a condenser system,
But Xenon lamp (cold light source) gives better visual
clarity. The light intensity can be regulated manually or
automatically. High intensity Xenon lamp gives better
visual and photographic clarity.
C. Light Cable
Light carrier is very important. It may either be a fluid or
a glass fibre light cable (fig. 3). In the cable, there should
not be sharp bends and cracks in the plastic sheath, if it
Laparoscopic Hand Instruments,
Accessories and ergonomics
Amitabh Goel
Figure 01: Laparoscopes
Figure 02: Light Source
2

10 Laparoscopic Hand Instruments Accessories and Ergonomics
is there, then the cable should be changed for good light
transmission. The cable is available at different diameters
and lengths. The diameter of the fibre bundle should
always be chosen slightly larger then the lens system and
should not be too long.
D. Cameras
Now high resolution, small and light weight cameras are
available, which is easy to handle, they provide picture of
optimal sharpness, high resolution and excellent colour
reproduction. A single chip camera has resolution of point
450-600; But the 3 chip cameras with more then 750
horizontal lines give excellent visual clarity. Usually single
chip camera is adequate for routine laparoscopic surgeries
but if surgery is recorded for later inclusion in larger film
or video production, three chip camera is preferable. Now
a recent version of digital 3 chip camaras with integrated
image processing modules is available (fig. 4).
E. Monitors
The videomonitormustgeneratehighresolutionimageafter
the S-VHS connection. Larger video screen is preferred,
20 inches and above, non flickering medical monitors with
high resolutions morethen camera is preferred (fig. 5).
II. GAS FOR PNEUMOPERITONIUM
Air was the first gas used to produce pneumoperitoneum,
but has largely been abandoned. The main disadvantage
of air is the risk of air embolism.
Characteristics of the ideal insufflating agent
1. The ideal insufflating agent during laparoscopic
procedures should be colorless, physiologically inert,
and non explosive in the presence of electrocautery or
laser coagulation.
2. Its solubility in blood should be high.
3. The insufflating gas should be readily available,
inexpensive, and nontoxic.
1. Carbon dioxide
Carbon dioxide is an odorless, colorless gas. It is a
readily available, stable, naturally formed in the tissues
and subsequently eliminated by the lungs. Due to these
features, Carbon dioxide is the most commonly used gas
for insufflation during laparoscopic procedure.
Advantages
1. It has relatively low risk of venous gas embolism
2. It does not support combustion
Disadvantages
1. Hypercarbia and acidosis
2. The direct effects of carbon dioxide and acidosis can
Figure 03: Light Cable
Figure 04: Camera
Figure 05: Monitor

lead to decreased cardiac contractility, pulmonary
hypertension and systemic vasodilation.
2. Nitrous Oxide
Nitrogen is biologically inert, colorless, gaseous element
that is found free in the air. Nitrous oxide has been
suggested for the procedures performed under local
anesthesia, or for patients with pulmonary disease
undergoing longer procedures.
Advantages
1. Insignificant changes in acid-base balance.
2. Decreased pain
Disadvantages
1. Supports combustion in the presence of hydrogen or
methane gas.
3. Helium (He)
Helium isacolorless,odorless,tastelessgasthatisobtained
from natural gas. This inert gas is neither combustible
itself, nor supports combustion. Helium is less soluble in
water than carbon dioxide.
Advantage
1. The main physiologic advantage is the minimal effect
on acid- base balance.
Disadvantages
1. The development of postoperative subcutaneous
emphysema has been observed, as it is relatively poorly
soluble in water.
2. Risk of venous gas embolism because it is less soluble
in water then carbon dioxide. It is more diffusible
because of its low density.
4. Argon
Argon gas is colorless, odorless, noncombustible, and
chemically nonreactive.
Advantage
1. The major physiologic advantage isstable acid base
status.
Disadvantage
1. The majorpossible physiologic disadvantageiscardiac
depression.
III. LAPROFLATTOR
The Electronic CO2 Laproflattor is a general purpose
insufflation unit for use in laparoscopic operations (fig.
6). Controlled pressure insufflation of the peritoneal
cavity is used to achieve the necessary work space for
laparoscopic surgery by distending the abdominal wall
and depressing the hollow organs. Automatic insufflators
allow the surgeon to preset the insufflating pressure
and it supplies gas until the required intra-abdominal
pressure is reached. The insufflator activates and delivers
gas automatically when the intra-abdominal pressure
falls because of gas escape or leakage from the ports.
Insufflation pressure can be continuously varied from 0 to
30 mm Hg; total gas flow volumes can be set to any value
in the range 0-9.9 liters/mm. Patient safety is ensured by
optical and acoustic alarms as well as several mutually
independent safety circuits. The important indicators of
insufflators are preset pressure, actual pressure, flow rate
and total gas used.
Figure 06: Insufflator
IV. SUCTION IRRIGATION M ACHINE
It is used for flushing the abdominal cavity and cleaning
during endoscopic operative intrusions. It has been
designed for use with the 26173 AR suction /instillation
tube. Its electrically driven pressure/suction pump is
protected against entry of bodily secretions. The suction
irrigation machine is used frequently at the time of
laparoscopy to make the field of vision clear. Most of the
surgeons use normal saline or ringer lactate for irrigation
purposes. Sometimes, heparinized saline is used to
dissolve blood clot to facilitate proper suction in case of
excessive intra-abdominal bleeding.

Suction and Irrigation hand apparatus
Irrigation and suction are very important during
laparoscopic surgeries specially to maintain clear visual
field and maintained hemostasis. It comes in 5mm and
10mm reusable sizes (fig 7). The suction tip is highly
Figure 07: Suction andIrrigation HandInstrument
useful for intermittent suction and as blunt dissecting
instrument in place of finger, as we use in conventional
surgeries.
V. OPERATIVE HAND INSTRUMENTS
Reusable and disposable instruments are commercially
available. Disposable instruments provide better
performance and higher safety on single use. To make
it cost effective the surgeon has to reuse the disposable
instruments after sterilisation. Reusable instruments are
significantly cheaper in the long run, however, they need
proper cleaning and maintenance.
A. Insuffalation cannulas
1. Veress Needle
Veress needle was invented by a chest physician for
aspiration of pleural effusion keeping in mind that its
spring mechanism and blunt tip will prevent the injury
of lung tissue. Veress needle consists of an outer cannula
with a beveled needle point for cutting through tissues
(fig. 8). Inside the cannula there is an inner stylet, which
is loaded with a spring. This spring springs forward in
response to the sudden decrease in pressure encountered
upon crossing the abdominal wall and entering the
peritoneal cavity. The lateral hole on this stylet enables
CO2 gas to be delivered intra-abdominaly.
Veress needle is used for creating initial
pneumoperitoneum so that the trocar can enter safely
and the distance of abdominal wall from the abdominal
viscera should increase. Veress needle technique is the
most widely practiced way of access. It is very important
to check veress needle every time before using it, for its (1)
potency and, (2) spring action. Veress needle is available
in three lengths 80mm, 100mm, 120mm. In obese patient
120mm and in very thin patient with scaphoid abdomen
80mm veress needle should be used. Veress needle should
be held like a dart at the time of insertion.
2. Hassan Cannula
It is less commonly used than veress. It usually reduces the
risk of vascular and hollow visceral injury. It is an extremely
safe instrument to enter the abdomen, especially in a patient
who has previously undergone intra-abdominal procedures.
This cannula consists of three pieces: a cone-shaped sleeve,
a metal or plastic sheath with a trumpet or flap valve, and a
blunttippedobturator.On thesheaththerearetwostrutsfor
affixing two fascial sutures. These sutures are then wrapped
tightly around the struts. Thereby firmly seating the cone-
shaped sleeve into the laparoscopic port. This creates an
effective seal to maintain penumoperitoneum.
Figure 08:VeressNeedle

Figure 10:Tips andT
rocars
the incidence of injury of viscera. Trocar and cannula
are of different sizes and diameter depending upon the
instrument for which it is used. The diameter of cannula
ranges from 3 mm to 30 mm; the most common size is
5mm and 10 mm (fig. 11).
Some new disposable trocar designs incorporate
unique design features such as direct serial incision of the
tissue under visual control [Excel trocar-(fig.12)].
Figure 09: Hassan Cannula
B. Trocars
The word “trocar” is usually used to refer to the entire
assembly but actual trocar is a stylet which is introduced
through the cannula. The trocars are available with
different type of tips (fig. 10). The cutting tips of these
trocars are either in the shape of a three edged pyramid or
a flat two edged blade. C onical tipped trocars are supposed
to be less traumatic to the tissue. The tip can be penetrated
through the parietal wall without cutting and a decreased
risk of herniation or haemorrhage is reported.
Cannulas are in general made from plastic or metal.
Plastic devices whether they are transparent or opaque,
need to be designed in such a way as to minimize the
reflection of light from the telescope. Reusable and
disposable trocars are constructed by a combination of
metal and plastic. The tip of disposable trocar has a two
edged blade. These are very effective at penetrating the
abdominal wall by cutting the tissue as they pass through.
Most of the disposable plastic trocar have a spring loaded
mechanism that withdraws the sharp tip immediately
after it passes through the abdominal wall to reduce
Figure 11: DifferentSizes ofT
rocars

Figure 13: Reducing Sleeve Figure 14: NeedleHolder
C. Reducing Sleeve
It is used to reduce the size of the port from 10mm to
5mm or 5mm to 3 mm, so that pneumoperitoneum is
maintained when ever surgeon changes the instrument
from larger diameter to smaller diameter (fig. 13).
D. Needle holder
Laparoscopic needle holder is available with a straight or
curved tip. Two needle holders are necessary to perform
swift endo-suturing, although endo-suturing can be done
satisfactorily with a single needle holder and a grasper. In-
line grip needle holders are ergonomically better than
pistol grip needle holder (fig. 14).
Figure 12: XcelT
rocar
All the cannulas have a valve mechanism at the top.
Always inspect the trocar to ensure that all the valves move
smoothly and, that the insufflation valve is closed (to avoid
losing pneumoperitoneum). The valves of cannula provide
internal air seals, which allow instruments to move in and
out within cannula without the loss of pneumoperitoneum.
These valves can be oblique, transverse, or in piston
configuration.Thesevalvescanbemanuallyorautomatically
retractable during instrument passage.
Surgeon should remember that sharp trocars although
looking dangerous are actually better than blunt ones,
because they need less force to introduce inside the
abdominal cavity and the chances of inadvertent forceful
entry of full length of trocar is lesser. The end of the
cannula is either straight or oblique. An oblique tip is felt
to facilitate the easy passage of the trocar through the
abdominal wall.

E. Port closure instrument
These are self innovative hand instruments to close the
laparoscopic ports, especially 10mm or larger ports, if
needed (fig. 15).
VI. OTHER HAND INSTRUMENTS
Disposable or Reusable Instruments (fig. 16)
Several factors should be considered atthe time of choosing
laparoscopic instrument, including cost, availability and
reliability. Reusable instruments are expensive initially
but in long run they are cost effective. In developing
countries, disposable instruments are very rarely used
because labour cost is low compare to the cost of disposable
instrument. In Europe and USA, surgeons often choose
to use disposable instrument in order to save high labour
cost. The disposable instruments are not sterilized
properly by dipping in gluteraldehyde because they are not
dismountable. Insulation of disposable instrument also can
be torn easily which can lead to electrosurgical injuries.
Laparoscopic hand instruments vary in diameter
from 1.8 to 12mm but majority of instruments are
designed to pass through 5 to 10mm of cannula. The
instruments are also of different lengths (vary from
company to company, usually varies from 18 to 45cm)
but they are ergonomically convenient to work with if
they have same length of approximately 36 cm in adult
and 28 cm in pediatric practice. Shorter instruments 18
to 25cm are adapted for cervical and pediatric surgery.
Certain procedures for adult can also be performed
with shorter instrument where the space is constricted.
Forty-five centimetre instruments are used in obese
or very tall patients. For better ergonomics half of the
instruments should be inside the abdomen and half
outside. If half of the instrument is in and half out, it
behaves like a class-1 lever; and it stabilizes the port
nicely and thus surgery becomes convenient.
Figure 15: DifferentTypes of PortClosure
Figure 16: Disposable (left)andReusable(right)HandInstruments

Most of the laparoscopic procedures require a mixture
of sharp and blunt dissection techniques, often using the
same instrument in a number of different ways. Many
laparoscopic instruments are available in both re-usable
and disposable version. Most re-usable instruments are
partially dismountable so that it can be cleaned and
washed properly. Some manufacturer have produced
modular system where part of the instrument can be
changed to suit the surgeon favorite attachment like
handle or working tip.
Most laparoscopic instruments like graspers and
scissors have basic opening and closing function. Many
instruments manufactured during past few years are able
to rotate at 360 degree angle which increases the degree
of freedom of these instruments.
Most of the hand instruments have three detachable
parts.
a. Handle
b. Insulated outer tube
c. Insert which makes the tip of the instrument.
a. Different Handles of Hand instrument (fig. 17)
Certain instrument handles are designed to allow locking
of the jaw. This can be very useful when the tissue needs
to be grasped firmly for long period of time preventing
the surgeons hand from getting fatigued. The locking
mechanism isusually incorporated into the handle so that
surgeon can easily lock or release the jaws. These systems
usually have a ratchet so that the jaws can be closed in
different positions and to different pressures. Most of
the laparoscopic instrument handles have attachments
for unipolar electrosurgical lead and many have rotator
mechanism to rotate the tip of the instrument. Some
multifunctional laparoscopic handles have attachment
for suction and irrigation.
The Cuschieri Ball Handle was invented by Prof.
Sir Alfred Cuschieri. This handle lies comfortably
in surgeon’s palm. This design reduces the fatigue of
surgeon and eases rotation of the instrument by allowing
rotation within the palm rather than using wrist rotation.
Squeezing the front of the handle between the thumb and
the first fingers increases the jaw closing force; squeezing
the rear of the handle between the thenar eminence of
the thumb and last fingers opens the jaws.
Cuschieri pencil handle also has great ergonomic
value specially when used with needle holder. This
handle allows the angle between the handle and the
instrument to be altered to suit the surgeon’s wrist angle.
The conveniently placed lever of this pencil handle
when pressed can change the angle. Just like ball handle,
pressure at the front increases the jaw closing force while
pressure at the rear opens the jaw.
b. Insulated outer tube (fig. 18)
The insulation covering of outer sheath of hand
instrument should be of good quality in hand instrument
to prevent accidental electric burn to bowel or other
viscera. Insulation covering may be of silicon or plastic.
At the time of cleaning the hand instrument, utmost care
should be taken so that insulation should not be scratched
with any sharp contact. A pin hole breach in insulation is
not easily seen by naked eye but may be dangerous at the
time of electro surgery.
Figure 17: DifferenttypesofHandles Figure 18: OuterSheeth

c. Insert of Hand Instrument (fig. 19)
Insert of hand instrument varies only at the tip. It may be
grasper, scissors, or forceps. This grasper may have single
action jaw or double action jaw.Single action jawopen
Figure 19: Inserts
less than double action jaw but close with greater force
thus, most of the needle holders are single action jaw. The
necessary wider opening in double action jaw is present
in grasper and dissecting forceps. Single action graspers
and dissectors are used where more force is required.
d. Different type of Graspers (fig. 20 & 21)
These graspers are good when you don’t have control
over depth and surgeon wants to work in single plane in
controlled manner particularly during adhesiolysis.
Figure 21: DoubleAction Jaw Graspers
e. Instruments for Sharp Dissection
1. Scissors
2. Electro surgery hook
3 . HF Electro surgery spatula (Berci)
4 . HF Electro surgery knife
5. Knife
Scissors (fig. 22)
Scissors are one of the oldest surgical instruments used
by surgeons. Scissors are used to perform many tasks
in open surgical procedure but its use in minimal access
surgery is restricted. In minimal access surgery scissors
require greater skill because in inexperienced hand it may
cause unnecessary bleeding and damage to important
structures.
Types of Laparoscopic Scissors
1. Straight Scissors
2. Curved Scissors
3. Serrated Scissors
4. Hook Scissors
5. Micro-tip Scissors
Spatula, Hook and Harmonic Scalpel (fig.23)
Spatula has a flat tip for dissecting the gall bladder from
the liver bed. It is much safer than the hook. Hook
has a L shaped tip. Usually it is used to dissect the gall
bladder from the bed of the liver. Some surgeons also
use this instrument for opening of the intestine. Now a
days in modern laparoscopic surgery ultrasonic scalpel
(Harmonic scalpel) is available for advanced procedures.
Figure 20: SingleAction Jaw Grasper
Figure 22: Scissors

Clip Applicator (fig. 24)
They are available as either disposable or reusable.
Reusables are of of three sizes, large, medium large and
medium. They are used to clip cystic artery and cystic
duct according to their size. Disposable clip applier comes
with preloaded 20 clipsper unit asthe Protack (commonly
used in mesh repair in hernia) comes in 30 per unit.
ERGONOMICS
• Word derivation: ergon
(arrangement)
(labor) and nomia
• Concept: of designing the working environment to
fit the worker, instead of forcing the worker to fit the
working environment
• Application: to make the O T more user-friendly, to
reduce stress, to increase efficiency and safety
• Includes: instrument, machines and O T design
• Involves: understanding the interactions between
humans with other elements in the system to optimize
human well-being and overall performance of the
system
Operative laparoscopy has changed the concept of
surgery from prolonged painful recuperative periods
with long scars of open surgery to short stay, painless, and
cosmetically satisfying surgery. This has been achieved
at the expense of surgeons’ discomfort and fatigue, thus
putting both the surgeon and patient at risk. Inadequate
knowledge about ergonomics together with ergonomically
deficient design of laparoscopic instruments has been
cited as possible causes.
Increased technological complexity and sometimes
poorlyadaptedequipmenthaveledtoincreasedcomplaints
of surgeons’ fatigue and discomfort during laparoscopic
surgery.
Ergonomic Variable
The important variables which have been studied include
hand size, handle to tip force transmission, optimum
height of the surgeon’s hand and height of the operating
table, view site in relation to monitor position and the
technique of gripping the instruments.
Hand size
Hand size is an important variable to consider when
designing laparoscopic hand tools. This is because
laparoscopic surgeons, especially women using glove
sizes 6.5 or smaller, experience musculoskeletal
problems while using common laparoscopic instruments.
Figure 24: ClipApplicator
Figure 23: Spatula,Hook andHarmonic Scalpel

Moreover, subjects who reported musculoskeletal
problems performed a significantly greater percentage
of laparoscopic cases and found the stapler and graspers
difficult to use for a greater percentage of time than those
not reporting problems.
Handle to tip force transmission
Data from the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) reveal that laparoscopic
instruments suffer from ergonomically inadequate handle
designs and inefficient handle to tip force transmission,
which lead to surgeons’ fatigue, discomfort, and hand
paresthesias. Studies quantifying forearm and thumb
muscle workload by processed electro-myogram (EMG)
demonstrated that the peak and total muscle effort of
forearm and thumb muscles were significantly greater
when the grasping task was performed using the
laparoscopic instrument. This was found to be more
prevalent among junior laparoscopic surgeons having less
than two years of experience.
Optimum height
Discomfort and difficulty ratings were lowest when
instrument handles were positioned at elbow height. The
position of laparoscopic instrument handles needed to be
close to surgeons’ elbowlevel to minimize discomfort and
upper arm and shoulder muscle work. This was found to
correspond to an approximate table height of 64 to 77 cm
above floor level.
Technique of gripping
Palm grip hand position with the pistol handle (thumb
outside the ring with the palm resting on the thumb
ring) is more efficient than the finger-in-ring grasp
because it significantly reduces the muscle forces
required for grasping with a laparoscopic instrument.
Many surgeons do, in fact, use the palm grasping hand
position for sustained grasping tasks during laparoscopic
surgery. Moreover, use of finger tips rather than finger
base during finger-in-ring grasp during tissue dissection
reduces discomfort.
Majority of the surgeons performing regular
laparoscopy are unaware of the complications of nerve
injury and neuropraxia following improper gripping
technique. Experience in laparoscopic surgery does play a
major impact on knowledge about ergonomical problems.
Operating for prolonged hours with eyes focused on
video monitors results in eye strains among laparoscopic
surgeons. Placement and adjustment of monitors have
little benefit in improving the situation though experience
resulted in some improvement.
Use of laparoscopy is associated with significant
ergonomic problems, hence propertraining and awareness
among laparoscopic surgeons is essential in India. This
is only possible if an authorized accreditation council
sets up guidelines and oversees the training programs,
thus making laparoscopy safer for both surgeons and
patients.
REFERENCES
1. Carol E.H. Scott-Conner, ‘The SAGES Manual’1998. Springer-
Verlag, New York, USA.
2. Dr. C. Palanivelu .CIGES Atlas of Laparoscopic Surgery 2000.
Jaypee Brothers M edical Publishers (p) Ltd. New Delhi, India.
3. Dr. Parveen Bhatia, Dr. Suviraj J. John 2003. Laparoscopic Hernia
Repair. Global Digital Services, New Delhi , India.
4. http://www.simbionix.com/LAP_Mentor.html
5. http://www.indianjsurg.com/article.asp? issn= 0972-2068;
year=2005; volume=67; issue=3; page=164;page=166
ACKNOWLEDGEMENTS
1. Dr. Vandana Bansal, MS, FAIS
Consultant Dept. of MAS, Choithram Hospital, Indore
2. Dr. S.P. Jaiswal, Ph.D., M BA
Consultant Dept of Pathology, Choithram hospital & Research
Centre, Indore.
3. Mr. Shailendra Carpentar, MBA
Computer Designer

INTRODUCTION
Laparoscopic surgery requires sophisticated and precisely
calibrated instruments. The fundamental difference
between instruments used in open surgery and those
utilized for laparoscopic surgery is that the latter are
more complex in design and yet delicate in construction.
Thus the laparoscopic instruments (LI) are more prone
to lodging of bioburden (micro-organisms and debris)
within their crevices. Thus, the LI are difficult to clean,
sterilize adequately and maintain as compared to their
counterparts used in open surgery. Moreover, owing to
their delicate design, gentlest methods have to be used for
cleaning aswell assterilization. Also, meticulous cleaning,
maintenance as well as sterilization are necessary so that
not to compromise the safety of the patient, the surgeon
or other operating room personnel. The increase in
complexity of the laparoscopic procedures as also the
emergence of resistant strains of bacteria, mycobacteria,
fungi and viruses has made it imperative to effectively
clean and disinfect instruments.
Sterilization is the absolute elimination or destruction
of all forms of microbial life. It can be achieved with
steam, gas or chemicals. On the other hand, disinfection is
the relative elimination of pathogenic organisms except
spores. Disinfection can be: a) High level - where all life
forms except the spores are destroyed, b) Intermediate
level - where some fungi, viruses and spores are spared,
or c) Low level - where fungi, viruses, spores and
mycobacteria remain undestroyed. For laparoscopic
instruments ideally sterilization or at least high level
disinfection should be used.
CLEANING AND STERILIZATION
Optimal processing of LI involvesseveralstepsthat reduce
the risk of transmitting infection from used instruments
and other items to health care personnel. These are 1)
Dismantling, 2)Decontamination, 3)Precleaning, 4)
Cleaning and rinsing, 5) Drying 6) Sterilization and 7)
Storage. For proper processing, it is essential to perform
the steps in correct order.
Most major hospitals have a Central Sterile Supplies
Department (CSSD) where the instruments are
transported from the operating room for processing.
Even in hospitals or nursing homes that do not have
an elaborate CSSD, the basic steps in processing of
instruments can be adhered to provided a well-established
protocol is in place, and designated personnel are given
the responsibility for the same. Proper processing of
instruments forms an integral aspect of their care and
this should undoubtedly go a long way in increasing their
life span and trouble-free service.
Dismantling
The design of LI should be such that they should allow
easy dismantling (Figure 1). Instruments that cannot be
dismantled completely are liable to harbour blood /debris
within the shafts and compromise safety of the patients
in whom they are used subsequently (Figure 2)
Decontamination
Decontamination is the process used to reduce bioburden
on reusable medical devices. The process begins in the
theatre itself with the nursing staff wiping off visible
Sterilization and Maintenance of
Instruments & equipment
Deepraj S.Bhandarkar,Avinash N.Katara
3

Figure 2: Blood drops (arrow) on theinsert becomeapparent on dismantling
theinstrument
blood tissue and body fluids from the instruments with
a damp sterile sponge. At the end of this all soiled or
contaminated instruments should be placed in a container
containing a disinfectant solution such as 0.5% chlorine
and allowing them to soak for 10 minutes (Figure 3).
Figure 4: Decontamination in a purpose-builtbathin theCSSD
The instruments should not be left in this solution for
longer period of time as they may get damaged. Once
the instruments reach the CSSD, a purpose-built bath is
used for decontamination of their decontamination prior
to proceeding with the next step in the cycle .
Modifications of the standard cleaning processes are
required to clean rigid endoscopic instruments effectively.
Instruments designed with an external gasket, an internal
seal that does not totally occlude the internal space, or
no gasket should be placed in the vertical position in
enzymatic cleaning and rinsing solutions, instead of the
standardhorizontal position, sothat the air trappedwithin
the instrument is allowed to escape and replaces with
the solution. All solutions should be irrigated through
cleaning ports of instruments. During the process of
manual cleaning, special attention should be given to
intricate and delicate operating mechanisms located at
the distal end of many instruments. An ultrasonic cleaner
will enhance the cleaning of hard-to-reach places. At the
end of decontamination, the instrument should be safe for
handling without exposure to blood-borne pathogens.
Figure 1:DismantlingoflaparoscopichandinstrumentsbypersonnelintheCSSD
Precleaning
After the instruments have reached the sterile supplies
processing area, which is preferably a controlled
environment, a pre-cleaning treatment with an enzymatic
product is recommended. A number of enzymatic
(Figure 5) products are available, viz. protease, lipase,
amylase, which are effective in enhancing the cleansing
process for difficult-to-clean instruments. These break
down blood and other protein soil and facilitate cleaning.
These enzymes are proteins, and must be removed by
thorough cleaning.
Figure 3: Instrumentssoaked in a disinfectant for decontamination

22 Sterilization and Maintenance of Instruments & Equipment
Figure 5: Enzymaticpreparation used for precleaning
Cleaning
Any instrument designed for autoclaving requires
specialised cleaning prior to sterilization. Users need
to ensure that no residual, proteinaceous material or
organic residue remains on the instrument surface.
This is particularly important wherethe instrument
has several small moving parts and crevices; build up of
residues may eventually lead to corrosive damage and
pathogenic colonization (bioburden). Many hospitals
adopt the technique of washing their instruments in soap
scrubs. Although physical cleaning is partially effective,
enzymatic and detergent based cleaners which dissolve
and lift organic material from the surface of instruments
are better suited to ensuring that instrument surfaces are
clear of blood and other body fluids and proteinaceous
material prior to the sterilization process.
For laparoscopic instruments this is best carried out
using soft brushes that allow the inner surfaces of the
instruments to be cleaned thoroughly (Figures 6 and 7).
Rinsing
Laparoscopic instruments are best rinsed in running
water so that all the particulate matter as well as residues
of chemicals used for contamination and cleaning
are completely cleared from them. It is useful to have
“cleaning guns” with fine, pointed nozzles to rinse the
Figure 6: Cleaningtheinstrument tip with a toothbrush.Inset shows dried
blood on thetip of a dissector.
Figure 7:A long soft brush cleans theinner surface of a laparoscopic cannula.
Figure 8: Rinsing ofinstruments underrunningwater
Figure 9:A waterjetbeing used to clean theshaft of hand instruments

shafts of the laparoscopic hand instruments (Figure 8).
The jet of water is able to clean these instruments far
better than rinsing them in stagnant water.
Ultrasonic Cleaner
A method of cleaning that is growing in popularity is
ultrasonic cleaning (Figure 10). This method is, by far,
the most efficient and effective available today. Its ease of
use and superior efficiency is quickly making ultrasonic
cleaning the preferred choice. In fact, ultrasonic cleaning
is 16 times more efficient than hand-cleaning. The
instruments are placed in the ultrasonic unit for 10-
15 minutes and use a neutral pH solution. Attention
should be given to the following points during ultrasonic
cleaning:
Figure 10: Ultrasoniccleaner
• Before placing into the ultrasonic unit, the instruments
are cleaned of all visible debris.
• It’s preferable not to mix instruments made of
dissimilar metals (such as aluminum and stainless) in
the same cycle.
• It is important to ensure that the instruments have
plenty of room. The ultrasonic cleaner should not be
overloaded.
• As with all types of cleaning, all instruments should
be opened so ratchets and box locks are fully exposed
to the cleaning process.
• Upon completion of the cycle, the instruments are
removed immediately and rinsed.
using an oven. The latter, however, may be available only
in CSSD units.
Sterilization
The Centers for Disease Control (CDC) recommends
that rigid laparoscopic instruments be sterile or, if that
is not feasible, that they be high-level disinfected. There
are three sterilization processes available to us - steam,
ethylene oxide and peracetic acid. Because of product
knowledge and proprietary design information, the
instrument manufacturer is the only one who can provide
sterilization recommendations.
Steam sterilization
Steam sterilization in an autoclave is one of the most
common forms of sterilization used in health care
facilities. Autoclaving at 121 0C for 15minutes is ideal
for all reusable metal instruments. It is effective, cheap
and non-toxic. Laparoscopes may be sterilized by flash
or vacuum steam sterilization. Before sterilization, all
instruments that are insulated, all silicone tubing, and
Figure 11: Drying of instruments with a jetof air.
Drying
T heinstrumentsshould bedried at theend of thecleaning
and rinsing cycle before they are packed for sterilization.
This is ideally achieved by using an air gun that blows all
the water droplets off the surfaces of instruments or by
Figure 12: Drying ofinstruments in an oven.

24 Sterilization and Maintenance of Instruments & Equipment
Figure 14: Packedtraysoflaparoscopicinstrumentsbeingloadedinahigh-speed
autoclave
all cords should be doubly wrapped in a cloth to prevent
contact with the hot metallic container (Figure 13). They
are then placed in the autoclave. Flash sterilization is
carried out at 135 0 C at 30 psi pressure for 60 minutes
(Figure 14). This method requires post-vacuum and dry
cycles. The instruments should rest on a sterilizer rack
for 45 minutes to prevent water condensation on the lens
Gas sterilization
Using ethylene oxide (EO) is suitable for all disposable
instruments, insulated hand instruments and tubings used
for gas, suction and irrigation (Figure 15). Endoscopic
instruments may be sterilized with either cold or warm EO
gas, depending on the manufacturer’s instructions. With
cold gas, the temperatureissetat850 C and the instruments
are exposed for 4 hoursand 30 minutes. Aeration must then
follow for 12 hours. Warm gas sterilization takes place at
145 0C for 2 hour 30 minutes, followed by 8 hoursaeration.
The advantages of EO are that the items are not damaged,
it isnon-corrosive to optics and it permeatesporous
Figure 15: Ethyleneoxidesterilizer
material. Its main disadvantages are its cost, toxicity, the
need for aeration and being a longer process.
High level disinfection
When sterilization is not available or feasible, high-level
disinfection (HLD) is used for instrument processing.
H L D eliminates bacteria, viruses, fungi, and parasites
but does not reliably kill all bacterial endospores, which
cause diseases such as tetanus, gas gangrene and atypical
mycobacterial infections. H L D is suitable for items that
will come in contact with broken skin or intact mucous
membranes. The effectiveness of H L D depends on (a)the
amount and type of microorganisms, organic material
(blood, other fluids, tissues), and other matter (such as
dirt) present on the instrument or other item and (b) the
amount of protection the item gives the microorganisms
(such as whether the item has grooves or other areas in
which microorganisms can hide).Therefore itisimportant
to decontaminate and thoroughly clean instruments and
other items before HLD.
Agents that are used for H L D include 2%
glutaraldehyde, 6% stabilized hydrogen peroxide and per acetic
acid (acetic acid/hydrogen peroxide).
Glutaraldehyde has the advantages of having good
biocidal activity, non-corrosive to optics and is active in
the presence of protein. Glutaraldehyde is irritating to the
skin, eyes, andrespiratorytract, especiallyatconcentrations
of 0.3 parts per million (ppm). The length of time that
commercially available glutaraldehyde solutions can be
used varies, usually from 14-30 days. It should be tested
daily with the manufacturer’s test strip. Always follow
the manufacturer’s instructions regarding proper storage
temperatures and expiration date. Solutions should be
replaced any time they become cloudy. The efficiency of
glutaraldehyde is influenced by the organic load, contact
Figure 13: Double wrapping of instruments beforeautoclaving.

time and use pattern, concentration, physical configuration
of instruments, temperature and pH. OSHA’s established
maximum allowable exposure limit for glutaraldehyde
is 0.2ppm. Fibreoptic light cords and telescopes need to
be soaked in 2% glutaraldehyde for at least 10 minutes.
Soaking should not exceed 20 minutes. The endocamera
may also disinfected by 10 minutes submersion in 2%
glutaraldehyde. Care must be taken to leave the plug
end of the cord outside the solution. Alternately, sterile
drape over the camera and cord can be used. Soakage of
other metallic instruments, including trocars, and hand
instruments, is now recommended for 60 minutes, to avoid
infection with atypical mycobacterial infection.
Formaldehyde, glutaraldehyde from phenolic derivatives,
iodophors, hypochlorites, phenolics and quartery
ammonium compounds are definitely unpopular and has
been condemned. Formaldehyde is potentially cancer-
causing and extremely irritating to the skin, eyes, nose, and
respiratory tract. Furthermore, its efficacy is found wanting,
and therefore, routine use of formaldehyde for sterilizing
instruments and other items is not recommended.
NEWER METHODS OF STERILIZATION
A priority for hospitals with high workload is the rapid
turnaround times for instruments that cannot be sterilized
satisfactorily with steam or dry heat. One of the newer
sterilizer system - STERRAD (Johnson & Johnson) - uses
hydrogen peroxide vapor and low-temperature gas plasma
to sterilize most devices quickly with no toxic residues.
Usually, the process takes about 75 minutes for wrapped
and dry instruments and devices. Inside the chamber,
a deep vacuum is drawn. Fifty-nine percent aqueous
hydrogen peroxide is vaporized into the chamber. The
product is then enveloped in the hydrogen peroxide vapor.
Following the diffusion of the gaseous hydrogen peroxide
through the load, chamber pressure is reduced, allowing
for the generation of low-temperature gas plasma. Radio
frequency (RF) energy is applied to the chamber via an RF
amplifier, inducing the plasma state. Reactive species are
generatedfrom thehydrogen peroxidein thisstate, reacting
with materials and each other. Once the high-energy
species have reacted, they recombine to form water vapor,
oxygen, and other non-toxic byproducts. Upon completion
of sterilization, instruments are dry for immediate use or
sterile storage. Thus, recontamination risk is minimized,
and since they remain sterile until their next use, time and
money is saved by avoiding reprocessing instruments if the
case in canceled or delayed. This system takes up minimal
space and requires no venting or water hookup. The only
Figure 16: STERRADsterilizer
utility requirement is electrical hookup.
STORAGE
Items should be used or properly stored immediately
after sterilization or H L D so that they do not become
contaminated. Proper storage is as important as proper
decontamination, cleaning, sterilization, or HLD. If
items are not stored properly, all the effort and supplies
used to properly process them will have been wasted, and
the items will be contaminated.
Specific instructions for proper storage depend on
whether sterilization or H L D has been performed, the
method used, and whether the items are wrapped or
unwrapped.
The shelf-life of a wrapped item is affected by a
number of factors, including:
• The type of packing material used
• The number of times the pack is handled
• The number of people who handle the pack
• The cleanliness, humidity, and temperature of the
storage area
• Whether the packs are stored on open or closed shelves
• W hetherdust covers(such assealedplastic bags)are used
For optimal storage, sterile packs are placed in closed
cabinets in areas that are not heavily trafficked, have
moderate temperatures, and are dry or of low humidity.
Under optimal storage conditions and with minimal
handling, properly wrapped items can be considered
sterile as long as they remain intact and dry.
Storage time andthe handling of sterilepacksshouldbe
kept to a minimum, since the likelihood of contamination
increases over time and with increased handling. When
in doubt about the sterility of a pack, consider it to be
contaminated and resterilize the item before use.

Many energy sources are available to cut, coagulate
and evaporate tissue. A complete understanding of the
equipment, energy source physics, potential hazards
and limitations is essential if energy source related
complications are to be reduced. Energy sources are
classified as electrical, laser, ultrasonic, and mechanical.
The surgeon must realize that the use of a specific
energy source does not in itself lessen the chance of a
complication. Energy sources such as electrical, laser,
ultrasonic and hydro energy have unique properties that
determine their effectiveness and limitations when used
during minimally invasive surgery. What is also true is
that a particular surgeon may be conversant or may have
mastered a particular technique which may not even be
familiar to another. It has thus been aptly pointed out
that “It’s not the wand but the magician which makes a
difference”
ELECTROSURGERY
Electrosurgery uses an alternating radiofrequency
current with a frequency of 500,000 to 2 million Hz per
second. This rapidreversalof current means that ion
positions across cellular membranes do not change. As a
result, neuromuscular membranes do not depolarize, and
there is no danger of cardiac defibrillation at these high
frequencies unlike householdcurrent,which with its low
frequency of 60 Hz, can produce ventricular fibrillation.
The terms electrocautery and electrosurgery are
often used interchangeably in modern surgical practice.
However, these terms define two distinctly different
modalities. Electrocautery is the use of electricity to heat
a metallic object which is then used to coagulate or burn.
It is important to realize, there is no current flow through
the object being marked or cauterized with electrocautery.
Electrosurgery, on the other hand, uses the electrical
current itself to heat the tissues. As a result, the electrical
current must passthrough the tissues to produce the effect.
The current then flows through the tissues to produce heat
from the excitation of the cellular ions.
PHYSICS
The basic principle of electrosurgery is that current
flowing through the body takes the path of least resistance
which in the body means tissues with maximal water
(thus electrical resistance is in inverse proportion to
water content). The most conductive is blood followed by
nerve, muscle, adipose tissue and finally least conductive
is the bone.
It is also important to remember that the path is
not always a straight one. As soon as the current passes
through a tissue it dessicates (dries out) the tissue because
of which the resistance of that tissue rises leading to non
conductivity and the current then takes the path through
adjacent tissues which have a lesser resistance. Hence the
flow pattern of current through live tissue can never be
predicted. Also this changing resistance of body tissue
during the current flow requires that electrosurgical
generators must deliver current at increasing voltages
that are matched to the expected tissue resistance of the
human body , otherwise, current flow can be too low
to produce the desired effect or too great, resulting in
injury. The current density is another important variable
energy sources in Laparoscopy
and their optimal use
Rajeev Sinha
4

determining the biological effect of the current and can
be defined as = amperes/area= amperes/cm2
T hisexplainswhythe pinpoint tip of an electrosurgical
pencil worksmoreeffectively than aspatula. It follows that
in laparoscopy, the less area of contact of the electrode at
the intended site of effect, the greater would be the effect.
The amount of heat released is directly proportional to
the resistance of the tissues.
There are 3 types of currents:
1. Direct current which is unidirectional and is also
known as galvanic current and is used in acupuncture
and endothermy but not for electosurgery.
2. Alternating current or AC where the flow changes in a
sinusoidal fashion and is used in electrosurgery.
3. Then there is the pulsed current where a high amount
of electrical energyisdischarged in averyshort time. It
is used for electromyography and nerve stimulation.
The current circuit has to be completed which is done
through eitherthe ground pad (which isincorrectlycalled
earth plate) which takes the current back to the machine
after travelling through the body (unipolar circuit). Thus
it should be the aim to minimize the distance between the
operating electrode and the ground pad. In the bipolar
circuit ,because both the positive and negative electrodes
are near to each other, the current flow inside the body is
minimal and is thus less damaging. The majority ( 85%)
of surgeons use monopolar electrosurgery, whereas the
rest use bipolar electrosurgery.
Electrosurgical generators are essentially of two types:
grounded and isolated. The newer isolated generators
eliminate the possibility of an alternate site burn by
requiring the current to return to the generator. In the
early grounded generators the current returned to earth
by any contact point and thus caused inadvertent burns.
Both the unipolar and bipolar circuits can further
be modified as open and closed circuit. Open circuit is
typically formed when the electrode does not make contact
with the tissues or the tissue in contact with the electrode
is already dessicated. In the circuit, the resistance increases
and generator increases the voltage to close the circuit and
the wave form also becomes erratic. The current in close
circuit is safe and delivers lesser voltage.
BIOPHYSICS
The electrosurgical effect on the tissue results in 3
definable effects
i. cutting
ii. coagulation and or fulguration
iii. dessication
True electrosurgical cutting is a noncontact activity in
which the electrosurgical instrument must be a short
distance from the tissue to be cut. If there is contact,
High Current density
Isolated Generator system

28 Energy sources in Laparoscopy and their optimal use
desiccation will ensue rather than cutting. Cutting
requires the generation of sparks of brief duration
between the electrode and the tissue. The heat from
these sparks is transferred to the tissue, producing
cutting. As electrons in the form of sparks bombard
cells, the energy transferred to them increases the
temperaturein acell. Asaresult, atemperature isreached
at which the cell explodes. The best wave for cutting
is a non modulated pure sine wave because current is
delivered to the tissue almost 100% of the time that the
electrosurgical delivery device is activated. If the cut is
made by keeping the probe in contact with the tissue
then it is not true cutting rather it is mechanical cutting
through cauterized tissue.
Fulguration also requires that there should be no
contact between the electrosurgical delivery device and
the tissue. In contrast to cutting, fulguration requires
short bursts of high voltage only 10% of the time to
produce sparks but a lowpower to produce coagulation as
compared to cutting. Coagulation and Fulguration thus
utilize higher voltage than cutting but the pause between
current flow is more (maximum pause in fulguration).
Both cause coagulative necrosis of tissues and fluid.
Desiccation is the process by which the tissue is heated
and the water in the cell boils to steam, resulting in a
drying out of the cell. Desiccation can be achieved with
either the cutting or the coagulation current by contact
of the electrosurgical device with the tissue because no
sparks are generated. Therefore, desiccation is a low
power form of coagulation without sparking, and it is the
most common electrosurgical effect used by surgeons.
The pure cutting current will cut the tissue but will
provide poor hemostasis. The coagulation current will
provide excellent coagulation but minimal cutting. The
blend current is an intermediate current between the
cutting and the coagulation current, as one might expect.
In actuality, it is a cutting current - the duty cycle or time
that the current is actually flowing during activation of
the electrosurgical delivery device is decreased from
100% of the time to 50% to 80%. It is important to note
that setting the generator to blend mode does nothing to
alter the coagulation current that is provided. Only the
cutting current is altered so that the duty cycle is reduced
to provide more hemostasis.
The use of electrosurgery in laparoscopic surgery
is complicated by the insufflating gas, which has a low
heat capacity. As a result, instruments may not cool as
rapidly as in the open environment. In addition the
high water content of the gas increases the conductive
capacity of the medium.
Despite new advances in machines which are safer,
complications can still occur and injuries like, bile leaks,
intestinal injuries , anastomotic leaks and postoperative
bleeding may result from the inappropriate or injudicious
use of electrosurgery. Fortunately most if not all injuries
can be eliminated by the use of isolated generators,
returns, electrode monitoring systems. and active
electrode monitoring systems.
“Pure Cut” “Blend 1” “Blend 2” “Blend3” “Pure Coag”
100% On 80% On 60% On 50% On 94% Off
20% Off 40% Off 50% Off 6% On
Low Voltage High Voltage
Blend currents. The blend current is a cutting in which the duty cycle has electrosurgical actions

COMPLICATIONS which can result from the use
of electrosurgey include.
• Grounding failures
• Alternate site injuries
• Demodulated currents
• Insulation failure
• Tissue injury at a distal site
• Sparking
• Direct coupling
• Capacitive coupling
• Surgical glove injury
• Explosion
Ground Pad Failures
The large surface area of contact it provides, allows the
current to be dispersed over a large enough area that the
current density at any one site on the electrode is small
enough not to produce thermal damage. Lack of uniform
contact can result in significant current concentration
and damage. Any conductive low resistance object can
“HOOK, LOOK, COOK”.
ELECTROSURGICAL PROBES
Ground pad burn
Ground pad burn

30 Energy sources in Laparoscopy and their optimal use
Ground pad burn
serve as the conduit. Exit of current at these alternate
sites can produce injury at an alternate site. Usually such
injury results when the site of contact is small, there by
providing a high current density.
Demodulated currents
Modern generators have filters that remove demodulated
currents from the current delivered to the patient so that
only electrical current of 250 to 2000 kHz is delivered.
Demodulated currents occur most commonly when an
electrosurgical instrument is activated off metal and then
touched to the metal, such as the common practice of
“buzzing a hemostat”. Demodulated currents produce
neuromuscular activity that is usually of no significance
unless directly coupled to the heart through a catheter
or during a cardiothoracic surgical procedure. Another
example of demodulated current is muscle fasciculation
at the site of a laparoscopic cannula during the use of
electrosurgery.
Insulation Failure
Insulation failure is thought to be the most common reason
for electrosurgical injury during laparoscopic procedures
and more commonly seen with high voltage coagulation
wave form. Voyles and Tucker have classified insulation
failure into four potential zones of injury. Zone 1 failures
are easily seen by the surgeon, Zone2 can only be seen after
careful inspection and because the break is small a high
current density is achieved. Zone3 is detected by appearance
of demodulated current induced fasciculations and Zone4 is
injurious to the surgeon or other personnel.The key factor
that determines the magnitude of injury from insulation
failure resides in the size of the break in the insulation.
Paradoxically, the smaller the break, the greater the
likelihood of injury if contact of tissue with that site occurs.
This is related to the concept of power density. Protection
against insulation failure is provided by the active electrode
Insulation failure from instruments
monitoring systemavailablein many machines.
Tissue injury
Current passing through structures of small cross
sectional area may have current concentrated there, with
resultant unintentional thermal injury. For example if the
testicle and cord are skeletonized and mobilized from the
scrotum, application of energy to the testicle can result
in damage to the cord,because the current must return
to the indifferent electrode through the small diameter
cord before it is dissipated in the body through numerous
pathways.Another example of cutting an adhesive band
fromthe gallbladderto theduodenumwithelectrosurgery.
If the adhesion is wider near the gallbladder than on the
duodenum, the current density will be greater on the
duodenum injuring the duodenum.
Sparking and Arcing
Jumping of sparks from the electrode to tissues is the
mechanism for fulguration and true electrosurgical
cutting. However, it can also occur in an unintended
Insulation failure zones

Dr Aloy J Mukherjee Best Laparoscopic Surgeon in Delhi NCR, Best Surgeon in Apollo Hospital, General Surgeon, Hernia Surgeon

Dr Aloy J Mukherjee Best Laparoscopic Surgeon in Delhi NCR, Best Surgeon in Apollo Hospital, General Surgeon, Hernia Surgeon

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