This document provides an overview of the setup for laparoscopic surgery, including the common instruments and equipment used. It discusses the key components of image production like the telescope, light source, video camera and monitors. Methods for creating pneumoperitoneum like the CO2 insufflator, Veress needle and trocars are explained. Finally, it briefly touches on gasless laparoscopy and the various operative instruments employed. The objectives are to familiarize participants with the standard laparoscopic setup and components.

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

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

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

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

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

57. Instruments cont…
• Some have an electrical adapter so they can
be combined with unipolar or bipolar
electrocoagulation.
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58. Needle holders
• These are essential to perform suture and
knots.
• There are different types of needle holders:
–Handle can be straight or curved.
–Tips can be straight or curved.
• The co-axial types with a locking system are
preferred to the pistol type needle holders
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59. Ligation clip system
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60. Ergonomics
• Ergonomics is the study of the psychologic and
physical interaction between the user (e.g.,
surgeons, assistants, or nurse) and their tools
• The “relationship” between the surgeon and
their tools determines how much effort is
expended by the surgeon.
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61. Ergonomics cont…
• Simple tasks are more stressful and fatiguing
during laparoscopic surgery leading to less
physical and mental reserve.
• The proper design of the instruments and the
set up (layout) of the operating room is critical
to avoid fatigue and human errors.
• This is why ergonomics is important.
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62. The surgeon’s mental and physical reserve during
laparoscopic surgery is significantly reduced compared
to open surgery.
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63. Ergonomics cont…
• The goal is:
–Make surgeon comfortable; neck and back
maintained in upright position facing
forward.
–Proper set up for comfort and efficient
movement, and thus minimization of the
risk of musculoskeletal injuries to the
operator.
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64. Ergonomics cont…
• During laparoscopic surgery, the ability to
achieve this ideal posture is determined by:
–The height of the operating room table
–The position of the visual display (e.g.,
monitor)
–Foot pedal locations
–The selection of hand instruments
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65. Operating Table Height
• The proper adjustment of the operating table
height is very important.
• Ergonomically, angle between upper and
lower arm should be between 90° and 120°
when performing manual work.
–The operating table should be elevated or
lowered to enable the surgeon to achieve
this window.
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66. Foot Pedals
• Foot pedals are commonly used during
laparoscopic surgery to activate instruments such
as the cautery, ultrasonic shears etc.
• Pedals should be;
– Placed near the foot
– Aligned in the same direction as the instruments,
toward the target quadrant and the principal
laparoscopic monitor.
• A pedal with a built-in foot rest is preferable
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67. Vertical Positioning of Video Monitor
• The position of the video monitor affects neck
and back posture.
• The display should be placed;
– Directly in front of the surgeon
– 15°–40° below eye level for maximum comfort
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68. Key elements of the ergonomic
laparoscopic surgeon
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69. Choosing Laparoscopic Instruments
• No single design is superior to others
• Each surgeon needs to choose the design(s) that
best achieves the following goals:
–Enables the surgeon to keep both wrists in a
neutral (unbent) position
–Permits the surgeon to keep both arms at the
sides of their body
–Avoids pressure points on the hands
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70. Choosing Lap. Instruments cont…
–Allows the surgeon to apply force with a
power grip (hammer or gunstyle) hand
position
–Allows fine manipulation with a precision
grip (pencil or forceps style) hand position
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71. Choosing Lap. Instruments cont…
• The most important features to look for in
laparoscopic instruments are these:
– Handles that are smooth and broad surfaced.
Avoids pressure points and finger entrapment
– Internal mechanism that is smooth, precise, and
allows good tactile feedback from the tip of the
instrument to the handle
– Easy and intuitive access for the fingers to any
additional controls that govern shaft rotation, jaw-
locking, or electrocautery or suction activation
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72. Choosing Lap. Instruments cont…
– Sturdy insulation of the instrument shaft all the
way to the base of the jaws to avoid stray
electrocautery injury during use
– An electrocautery connector pin that keeps the
electrocautery cable out of the way of the
surgeon’s hand during use of the instrument
– Instruments that require substantial force to use
(staplers, clip appliers, heavy graspers) should
have a broad and smooth pistol-type hand that
permits the surgeon to use a power-grasp hand
position
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73. Laparoscopic Surgical Technique
• Performing laparoscopic surgery requires the
proper placement of the access ports and the
efficient and safe use of the instruments to
accomplish tissue dissection, division, sealing,
and re-approximation.
• The location of the access ports is critical because
they determine the reach and the working angle
of the instruments passed through them.
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74. Laparoscopic Surgical Technique cont..
• A manipulation angle range of 45°–75° (in the
horizontal plane, the acceptable range of
angles between the instruments inserted
through the different ports) with equal
azimuth angles (the elevation angle range in
the vertical plane) is recommended.
• Ideally, the surgeon maintains similar
elevation angles for each of the instruments
that they hold.
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75. Laparoscopic Surgical Technique cont..
• Instruments should be inserted such that at
least half of the instrument is inside the
patient.
• If the instrument is utilized while inserted less
than half of its length, excessive motion at the
shoulder will be required, which is likely to
fatigue the surgeon
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76. Laparoscopic cholecystectomy
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77. Laparoscopy in Perforated Peptic
Ulcer:
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78. Laparoscopic appendectomy
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80. Endoscopic pre-peritoneal inguinal
hernia repair (TEP)
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81. Laparoscopic ventral hernia repair
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82. 6/1/2023 Dr.Rama-Set up for laparoscopic surgery 82

83. single-incision laparoscopic
gastrectomy
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84. Questions?
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85. Thank you for your
attention
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