Laproscopy

1. LAPAROSCOPY CART & INSTRUMENTS
Guide: Lt Col (S) Jigi George
NOIC OT
CH SC Pune

2. INTRODUCTION
Laparoscopic surgery, also called
minimally invasive surgery (MIS) or
keyhole surgery, is a modern surgical
technique in which operations are
performed far from their location through
small incisions (usually 0.5–1.5 cm)
elsewhere in the body.
Three main
Components:
Image
production
Pneumoperiton
eum
Laparoscopic
instruments

3. PRINCIPAL OF LAPAROSCOPY
Identification of pathology and
surgical intervention is the sole
principal of laparoscopy.

4. Equipment cart
Imaging system
Insufflating
system
Instrumentations
Electro-surgical-
cautery system
Suction and
irrigation system
COMPOSITION OF A LAPAROSCOPE

5. LAPROSCOPE CART
source shelf Electro-surgical
Figure: Equipment cart
Camera reader shelf
shelf
Co2 insufflators shelf Light
Monitor shelf

6. LAPAROSCOPIC INSTRUMENTATION
1. Optical Devices
2. Equipment for creating / maintaining domain
3. Instruments for Access
4. Operative instruments
5. Energy sources
6. Tissue approximation/ hemostasis

7. OPTICAL DEVICES
Telescope:
• This endoscope is made of surgical stainless steel containing an optical lens
train comprised of precisely aligned glass lenses and spacers (Rod lens system)
• Telescopes or laparoscopes come in various sizes
• 0 degree telescope
• 30 degree telescope
• 45 degree telescope

9. White light illumination is provided from a high- intensity xenon, mercury, or
halogen lamp and delivered via a fiberoptic bundle.
Light source:

10. There are two types of cables
Fiberoptic cables are flexible but do not
transmit a precise light spectrum.
Fluid cables transmit more light and a
complete spectrum but are more rigid.
Fluid cables require soaking for
sterilization and cannot be gas sterilized.
LIGHT CABLE

11. The basis of laparoscopic cameras is the solidstate silicon computer chip or CCD (charge-coupled
device).
The resolution or clarity of the image depends upon the number of pixels or light receptors on the
chip.
Standard cameras in laparoscopic use contain 250,000 to 380,000 pixels.
VIDEO CAMERA

12. High-resolution video monitors are required .Three chip cameras require monitors
with 700 lines resolution to realize the improved resolution of extra chip sensors.
VHS recorder, video printer and sometimes DVD recorder are standard
documentation equipmentS housed in the video cart.
TELEVISION MONITOR

13. EQUIPMENT FOR CREATING /
MAINTAINING DOMAIN

14. CO2 Insufflator: The creation of working space in the abdominal cavity is generally
done using CO2 delivered via an automatic, high flow, pressure regulated insufflator.
CO2 is currently the agent of choice due to low risk of gas embolism, low toxicity to
peritoneal tissues, rapid reabsorption, low cost and inhibits combustion.
The insufflator delivers gas at a flow rate of up to 20 liters / min.
level is usually set at 12 to 15 mm Hg.
GAS INSUFFLATION

15. CO2 CABLE
Connected to insufflators
Connected to CO2 port of trocar

16. INSTRUMENTS FOR ACCESS
Veress needle
• The Veress needle is designed to create pneumoperritoneum prior to insertion of trocar
in a closed fashion.
• It consists of an outer sharp cutting needle and inner blunt spring-loaded obturator.
Hasson’s cannula
• used for gaining initial access to the abdominal cavity with
• an open cutdown technique.
Optical trocar: allows visualization of the tissues as the blade cuts
through the layers of the abdominal wall.

17. OPERATIVE INSTRUMENTS
Trocars:
Available in various diameters and sizes according to requirements,
10mm and 5 mm being commonly used.
They are Bladed and nonbladed types.
Of the bladed trocars, there are shielded and nonshielded types.

18. OPERATIVE INSTRUMENTS

19. MAIN PARTS OF LAPROSCOPIC
INSTRUMENTS
Tip

20. GOOD QUALITIES OF A LAPROSCOPIC
INSTRUMENT
It is usually 33 cm long
Jaws to be adequately elastic to perform atraumatic handling
Easy to disassemble and reassemble
Parts should be interchangeable between similar instruments
Easy cleaning and sterilization
Simple design with minimum number of hinges and bolts

21. Bullet Nose Grasper with either straight or diamond-cut serrations has a blunt
bullet nose tip design with an atraumatic grasping jaw (one that will not produce
tissue damage)..
Dorsey Intestinal Fenestrated Grasper has atraumatic horizontal serrations.
Bullet nosegrasper Dorsey intestinal grasper
GRASPERS

22. Crocodile Grasper has long contoured jaws with tissue herniation channels to ensure
superior grasping ability.
Raptor Grasper has long contoured jaws with tissue herniation channels. It also has two
atraumatic teeth at the tip for grasping difficult anatomy.
Hunter Bowel Grasper has two rows of atraumatic serrations. The jaw comes in
different lengths,depending on the needs of the surgical procedure.
⚫Hunterbowel grasper
Crocodile graspers Raptorgrasper
GRASPERS

23. GRASPER

24. Maryland Dissector has long, curved jaws with fine- tapered tips. Ideal for
precise dissection.
Bipolar Dissector - It is used to achieve hemostasis.
Maryland dissector Bipolar dissector
DISSECTORS

25. There are a variety of scissors for dissecting, mobilizing and
cutting tissues, which include straight and curved types (Endo
Shears). Hook scissors are used to cut sutures, tough fibrous
tissues. Most dissecting scissors have adapters for diathermy.
SCISSORS
Scissors Hook scissors

26. Tubular structures, bowel and lung can be held with
instruments designed specifically for the same.
BOWEL AND LUNG CLAMP:
Endo babcock Endo lung clamp

27. ASPIRATION & IRRIGATION PROBES
These are essential for most laparoscopic procedures
in order to maintain a clear operative field.
Figure: Suction thumb control
Port for irrigation
Thumb control
This end is placed
in abdominal cavity
Part for drainage

28. ENERGY SOURCES
Electrocautery refers to direct current whereas electrosurgery uses
alternating current.
During electrocautery, current does not enter the patient’s body. Only
the heated wire comes in contact with tissue.
In electrosurgery,the patient is included in the circuit and current enters
the patient’s body.
Electrosurgery:

29. incorporates a stream of argon gas to
improve the surgical effectiveness of the
electrosurgical current.
ARGON-ENHANCED ELECTRO
SURGERY

30. Uses ultrasonic technology, the unique energy form that allows both cutting and
coagulation at the precise point of impact,resulting in minimal lateral thermal
tissue damage.
Coagulation occurs by means of protein denaturation when the blade, vibrating
at 55,500 Hz, couples with protein, denaturing it to form a coagulum that seals
small coapted vessels.
ULTRASONIC ENERGY
(THE HARMONIC SCALPEL)

31. INSTRUMENTS FOR TISSUE
APPROXIMATION/ HEMOSTASIS

32. LAPAROSCOPIC LIGATING SUTURE
DELIVERY SYSTEM
• A Pre-tied sliding knot with a loop is available with nylon carrier rod to ligate stump
like structures or tubular structures after cutting. Eg Surgitie.
• The suture is looped around the structure to be ligated and the knot is slid down to
close the loop.
• Useful in appendicectomy.
Surgitie Knot pusher

33. Endo stitch is a 10mm disposable suturing device. The needle features a sharp
tapering point at each end with suture attachment at the center of the needle.
The double-ended needle is passed between the two jaws of the suturing device.
Its advantages include easy introduction, atraumatic needle manipulation, good
security and easy accurate needle placement.
Needle holder Endo-stitch
NEEDLE DRIVERS

34. CLIP APPLICATORS
Clip appliers are primary modality for ligating blood
vessels.

35. MECHANICAL STAPLING INSTRUMENTS
Laparoscopic staplers are modifications of stapling devices of open surgery. Staplers
are used for transecting and anastomosing bowel, transecting mesentery etc.
A range of staple lengths (2.5-3.8mm)is available depending on the thickness of the
tissue to be divided.

36. These are pre loaded specimen retrival pouches made of strong
material, which is impervious to cancer cells. The mouth of the
pouch is bought out of the incision site and opened following
which the specimen is extracted.
Specimen retrieving bag
ORGAN EXTRACTION DEVICES

37. TISSUE MORCELLATORS
These are used to reduce the size of the resected specimen prior to retrieval.
It may render pathological examination more difficult.
Eg.Laparoscopic myomectomy.

38. Balloon dissector is a space dissector which functions when
saline or air instilled into the pre-shaped balloon inserted into
the intended region.
These are used for laparoscopic extraperitoneal surgery eg
hernia repair,endoscopic neck surgery, subfascial endoscopic
ligation of perforators veins, retroperitoneal surgery, etc.
Balloon dissector:
SPACE CREATORS

39. ‘Critical’ equipment require Sterilization / High level disinfection
CARE OF LAPROSCOPIC EQUIPMENTS
Dr Shashwat Jani.
99099 44160.
26-Feb-18
3
9

40. Essential to perform the steps in correct
order . . .
Dr Shashwat Jani.
99099 44160. 26-Feb-18 4
0
Dismantling,
Decontamination,
Pre cleaning,
Cleaning and rinsing,
Drying
Sterilization and
Storage

41. WASHING / CLEANING
Manual,
mechanical or
ultrasonic
cleaning
Rinse & Dry
Visual Check
Lubrication
Assemble
Disassemble

42. METHODS OF DISINFECTION
Dr Shashwat Jani.
99099 44160. 26-Feb-18 42
Low temperature steam – 73oC x 20 mins
Glutaraldehyde 2% - effective against most bacteria, virus
including hepatitis B & C / HIV
Cidex solution - ( 2.4% alkaline glutaraldehyde) provides high
level disinfection in 20 – 45 mins.
Ortho phthalaldehyde 0.55% (OPA) - 12 mins soak time at
room temp.
Perasafe - 0.08% Peracetic acid plus 1.0% hydrogen peroxide -
Soak time - 10 mins

43. STERILIZATION METHODS
Ethylene
Oxide
Chemical
Disinfection
Formaldehyde
Cabinets?
Newer
methods…..

44. ETHYLENE OXIDE STERILIZATION
• Temp & duration
– 54oC
– 37oC
150min 5
hours
(Aeration cabinet >24hrs)
• Use for
– Heat sensitive items
• Monitor
– Indicator strips
• Dangers to Staffs
– Inhalation injury
– Contact injury
• Expensive
26-Feb-18
99099 44160.
Dr Shashwat Jani.
2

45. NEWER METHODS OF STERILIZATION
Gas Plasma sterilization
( STERRAD )
Steris System
•Hydrogen peroxide
•30 min at 500C
•For heat sensitive items
•Small trays/Special packing
99099 44160.
•Peracetic acid
•30 min at 500C
•For heat sensitive items
•Point of use system

46. FORMALIN CHAMBERS
Dr Shashwat Jani.
99099 44160.
26-Feb-18 46

47. NATIONAL SURVEY ON STERILIZATION
METHODS
Formalin Chamber
53%
2%Cidex
39%
Ethylene Oxide
1%
Autoclave
7%
Formalin Chamber
2%Cidex
Ethylene Oxide
Autoclave