EXTENSIVE COVERAGE OF LAPAROSCOPIC INSTRUMENTS AND THEIR ERGONOMICS TO HELP SURGEONS TO KNOW HOW TO USE THEIR LAP INSTRUMENTS IN MOST APPROPRIATE WAY AND THEIR ERGONOMICS TO BE COMFERTABLE DURING SURGERY AND PATIENTS LIFE ALSO MORE SAFE.

1. Dr. Ajay Jain
MBBS, MS, FIAGES, FMAS, FALS
ASSOCIATE DIRECTOR ,DEPT. OF GENERAL &
MINIMAL ACCESS SURGERY
MAX SUPERSPECIALITY HOSPITAL ,VAISHALI
,GHAZIABAD
Dr. Anubhav Singh
MBBS, DNB(General & Laparoscopic Surgery)
RESIDENT SURGEON, DEPT. OF GENERAL &

2.  LAPAROSCOPIC PROCEDURES ARE INHERENTLY
COMPLEX
 VISUALIZATION & TACTILE EXPLORATION OF
OPERATIVE FIELD IS INDIRECTLY ACHIEVED
THROUGH OPTICAL SYSTEMS & INSTRUMENTS
 EQUIPMENT & INSTRUMENTATION HAVE GREATER
IMPACT & IMPORTANCE
 SURGEON MUST BE FAMILIAR WITH EQUIPMENT TO
USE , TROUBLE SHOOT & SOLVE PROBLEMS

3. IMAGING SYSTEM
 LAPAROSCOPE
 LIGHT SOURCE
 LIGHT CABLE
 CAMERA
 MONITOR
 RECORDING DEVICES

4. LAPAROSCOPES
 RIGID / FLEXIBLE ( FIBREOPTIC )
 0 , 30, 45 DEGREES
 3, 5, 10 MM - DIAMETER
 36 , 45 CMS – LENGTH
 NEWER INNOVATION IS 4K LAPAROSCOPES

5. LIGHT SOURCE
 HALOGEN -250 WATT LAMP
 XENON- 175 / 300 WATT
 LED
 LIGHT INTENSITY REGULATED MANUALLY OR
AUTOMATICALLY
 Brightest to darkest measured in units of decibels.
 White balance by making sure white is correct then all the
colours through the spectrum are correct.

6. LIGHT CABLE
 FLUID FILLED CABLE
 GLASS FIBRE CABLE

7. CAMERAS
 SINGLE CHIP CAMERA – RESOLUTION 480-600 LINES
 THREE CHIP CAMERA –RESOLUTION MORE THAN 750
HORIZONTAL LINES
 DIGITAL THREE CHIP CAMERA – WITH INTEGRATED
IMAGE PROCESSING MODULES

8.  CHIP: THIS IS ALSO CALLED A CHARGED COUPLED
DEVICE ( CCD )
 THESE ARE FLAT SILICONE WAFERS WITH A MATRIX, A
GRID OF MINUTE IMAGE SENSORS
CALLED PIXELS.
 HD (1280 x 720 p resolution )
 FULL HD CAMERA (1920 x 1080 p resolution)
 3D CAMERA
 4k UHD CAMERA (4096 x 2160 p resolution)
 8k UHD CAMERA (7680 x 4320 p resolution)
 Camera head consists of a goal lens , a prism assembly and
three sensors for acqurining the primary colours of the
image.

9. MONITORS
 GENERATE HIGH RESOLUTION IMAGES
THROUGH S-VHS / COMPOSITE / DVI
CONNECTION
 LARGE SCREEN 20” OR MORE PREFERRED
 NON FLICKERRING

10. RECORDING DEVICES

11. GASES FOR PNEUMOPERITONEUM
 IDEAL GAS : COLOURLESS , PHYSIOLOGICALLY INERT ,
NON EXPLOSIVE IN PRESENCE OF ELECTROCAUTERY
OR LASER COAGULATION
 HIGHLY SOLUBLE IN BLOOD
 READILY AVAILABLE , INEXPENSIVE & NON TOXIC
 CO2 IS MOST COMMONLY USED – ODOURLESS ,
COLOURLESS , READILY AVAILABLE , STABLE ,
NATURALLY FOUND IN TISSUES & SUBSEQUENTLY
ELIMINATED BY LUNGS
 OTHER GASES USED ARE NITROUS OXIDE, HELIUM,
ARGON

12. LAPAROFLATOR
 ELECTRONIC CO2 LAPAROFLATOR
IS INSUFFLATION UNIT
 ALLOWS PRESET PRESSURE &
FLOW
 INSUFFLATION FLOW RATE VARIES
FROM 1-40LITRES PER MINUTE
 NEWER ONES DELIVER
HUMIDIFIED/ WARM GAS TO
REDUCE FOGGING OF LENS

13. SUCTION IRRIGATION MACHINE
 USED FOR FLUSHING &
CLEANING ABDOMINAL CAVITY
 DESIGNED FOR USE WITH 26173
AR SUCTION / INSTILLATION
TUBE
SUCTION IRRIGATION HAND
INSTRUMENT :
 SIZES COME IN 5/10MM
DIAMETERS
 USED FOR INTERMITTENT
SUCTION & BLUNT DISSECTION

14. OPERATIVE HAND INSTRUMENTS
VERESS NEEDLE
 USED FOR CREATING
PNEMOPERITONEUM
 CONSISTS OF OUTER CANNULA &
BEVELED NEDDLE POINT FOR
CUTTING THROUGH TISSUE , INNER
STYLET LOADED WITH SPRING WITH
LATERAL HOLE
 EXTERNAL DIAMETER 2.2MM &
INTERNAL 1.2MM
 SIZES : 80 MM ( PEDIATRIC ) / 100 MM
/ 120 MM ( OBESE )

15. HASSAN CANNULA
 A SAFETY CANNULA
 CONSISTS OF CONE SHAPED SLEEVE METAL OR
PLASTIC SHEATH WITH TWO TRUSTS FOR
AFFIXING FASCIAL SUTURES
 TRUMPET OR FLAP VALVE
 BLUNT TIP OBTURATOR

16. TROCARS
THE TROCAR HAS A BLADE WITH A SHAFT AND BODY.
REUSABLE :
 COMBINATION OF METAL & PLASTIC
 TIP HAS TWO EDGED BLADE WHICH EFFECTIVELY
PENETRATES THE ABDOMINAL WALL
 DISPOSABLE :
 HAS SPRING LOADED MECHANISM WHICH
WITHDRAWS SHARP TIP IMMEDIATELY AFTER IT
PASSES THROUGH THE ABDOMINAL WALL
DIFFERENT TIPS :
 3EDGED PYRAMIDAL
 FLAT TWO EDGED BLADE
 CONICAL
DIAMETRS : 3-30MM
 COMMONLY USED 5-10MM

17.  ALL TROCARS HAVE VALVE
MECHANISM AT THE TOP
MANUAL OR AUTOMATIC,
WHICH ALLOWS INTRUMENT’S
PASSAGE IN AND OUT & ALLOWS
INTERNAL AIR SEAL
 END OF CANNULA IS STRIGHT OR
OBLIQUE
 OBLIQUE : BETTER FOR PASSAGE
OF INSTRUMENT
 EXCEL TROCARS HAVE UNIQUE
DESIGNS AND FEATURES SUCH
AS DIRECT SERIAL INCISION OF
TISSUE UNDER VISUAL CONTROL

18. REDUCTION SLEEVE
 REDUCE SIZE OF PORT FROM 10-5
OR 5-3 TO MAINTAIN
PNEUMOPERITONEUM
WHENEVER SURGEON CHANGES
INSTRUMENT FROM LARGER TO
SMALLER DIAMETER

19. NEEDLE HOLDER
 LAPROSCOPIC NEEDLE HOLDERS ARE AVAILABLE
WITH
STRAIGHT
CURVED TIP
ERGONOMICS BETTER IN INLINE GRIP > PISTOL GRIP

20. PORT CLOSURE
 INNOVATIVE HAND INSTRUMENTS TO CLOSE
PORT 10MM OR LARGE IF NEEDED

21. OTHER HAND INSTRUMENTS
DISPOSABLE OR REUSABLE
 REUSABLE ARE EXPENSIVE INITIALLY BUT ARE
COST EFFECTIVE, DISMOUNTABLE : CAN BE
WASHED AND CLEANED PROPERLY
 DISPOSABLE ARE NOT DISMOUNTABLE, NOT
STERILISED PROPERLY
 DIAMETER VARIES FROM 1.8-12MM
 MAJORITY DESIGNED TO PASS THROUGH 5-10MM
CANULA
 LENGTH VARIES 18-45cms (28 FOR PEDIATRICS;
36CMS IN ADULTS AND 45 CMS IN OBESE)

22.  FOR BETTER ERGONOMICS HALF INSTRUMENT
SHOULD BE INSIDE HALF OUTSIDE TO STABILIZE
THE PORT NICELY; BEHAVES LIKE CLASS 1 LEVER
 MOST INSTRUMENTS LIKE SCISSORS AND
GRASPERS HAVE OPENING AND CLOSING
FUNCTION
 MOST OF THEM CAN ROTATE AT 360 DEGREE
ANGLE

23. Fulcrum Effect of Hand Instruments
1: 1

24.  MOST OF THESE INSTRUMENTS HAVE THREE
DETACHABLE PARTS
1. HANDLE
2. INSULATED OUTER TUBE
3. INSERT WHICH MAKES TIP OF
INSTRUMENT

25.  DIFFERENT HANDLES
 LOCKS AND WITHOUT LOCK
 LOCKING MECHANISM IS INCORPORATED IN
HANDLE WHERE TISSUE NEEDS TO BE GRIPPED
FIRMLY SO THAT SURGEON CAN LOCK OR UNLOCK
EASILY
 PREVENTS FATIGUE ON PROLONGED USE
 HAS RACHETS SO AS TO CLOSE IT IN DIFFERENT
POSTIONS AT DIFFERENT PRESSURE
 INSTRUMENT HANDLES HAVE ROTATOR MECHANISM
TO ROTATE THE TIP AND ATTACHMENT FOR
UNIPOLAR OR BIPOLAR ELECTRO SURGICAL LEAD

26.  CUSCHIERI BALL HANDLE WAS INVENTED BY SIR
ALFRED CUSCHIERI
 LIES COMFORTABLY IN SURGEONS PALM;
REDUCES FATIGUE AND EASES ROTATION
WITHIN PALM RATHER THAN AT WRIST

27.  INSULATED OUTER TUBE
 INSULATION SHOULD BE GOOD TO PREVENT
ACCIDENTAL OR ELECTRIC BURNS TO BOWEL OR
OTHER VISCERAS
 MADE OF SILICON OR PLASTIC
 PINHOLE BREACH IS NOT SEEN WITH EYES BUT
COULD BE DANGEROUS AT THE TIME OF
ELECTROCAUTERY

28.  INSERT
 VARIES ON TIP-GRASPERS ,SCISSORS ,FORCEPS
 SINGLE ACTION JAW- OPENS LESS BUT CLOSES
WITH MORE FORCE
 DOUBLE ACTION JAW-WIDE OPENING, LESS
FORCE REQUIRED TO CLOSE

29. GRASPERS
 DIFFERENT TYPES OF GRASPERS ARE AVAILABLE
LIKE ATRAUMATIC BOWEL GRASPERS
 GOOD WHEN WORK IS DONE IN SINLGE PLANE
IN CONTROLLED MANNER PARTICULARLY IN
ADHESIOLYSIS

30.  INSTRUMENTS FOR SHARP DISSECTION
1. SCISSORS
2.ELECTROCAUTERY HOOK
3. HF ELECTROCAUTERY SPATULA
4. HF ELECTROSURGERY KNIFE
5. KNIFE
6. HARMONIC (ULTRASONIC) SHEAR

31. SCISSORS :
 STRAIGHT SCISSORS
 CURVED SCISSORS
 SERRATED SCISSORS
 HOOK SCISSORS
 MICRO SCISSORS

32.  SPATULA/HOOK/ULTRASONIC SHEAR
 SPATULA HAS FLAT TIP FOR
DISSECTION
 HOOK HAS L SHAPED TIP USED
FOR SHARP DISSESCTION AND
WIDE ANGLE FOR HEMOSTASIS
 HARMONIC SCALPEL FOR
ADVANCED PROCEDURES

33. CLIP APPLICATORS
 DISPOSABLE-PRELOADED WITH 20 CLIPS
 REUSABLE- LARGE/ MEDIUM LARGE/ MEDIUM
 USE CLIPS VARYING FROM LT 200/300/400

34. EXTRACTORS
 STONE EXTRACTOR
 10 MM EXTRACTOR WITH JAWS

35. ERGONOMICS
 WORD DERIVATION- ERGON (LABOR) NOMIA
(ARRANGEMENT)
 CONCEPT: OF DESIGNING THE WORKING
ENVIRONMENT TO FIT THE WORKER INSTEAD OF
FORCING THE WORKED TO FIT THE ENVIRONMENT
 APPLICATION: TO MAKE OT MORE USER FRIENDLY,
TO REDUCE STRESS, TO INCREASE EFFICIENCY AND
SAFETY
 INCLUDES INSTRUMENTS MACHINES AND OT
DESIGNS

36.  INVLOVES UNDERSTANDING INTERACTION
BETWEEN HUMANS AND OTHER ELEMENTS IN
THE SYSTEM TO OPTIMISE HUMAN WELL BEING
AND OVER ALL PERFORMANCE OF THE SYSTEM

37. ERGONOMIC VARIABLE
IMPORTANT VARIABLES WHICH HAVE BEEN
STUDIED INCLUDE
 HAND SIZE
 HANDLE TO TIP FORCE TRANSMISSION
 OPTIMUM HEIGHT OF SURGEONS HAND
 HEIGHT OF OPERATING TABLE
 VIEW SITE IN RELATION TO MONITOR POSITION
 TECHNIQUE OF GRIPPING INSTRUMENTS

38. Open Surgeon Vs Lap Surgeon
How do they differ?!
 Open Surgeon
 • Fast
 • Hand is as good as eyes
 • Dissection precedes
 • Ergonomics: Optional
 Laparoscopic Surgeon
 • Slow and steady
 • Stop when you don’t see
 • Haemostasis precedes
 • Ergonomics: Vital

39. HAND SIZE
 LAP SURGEONS USING GLOVE SIZE 6.5 OR LESS
EXPERIENCE MUSCULOSKELETAL PROBLEMS

40. TECHNIQUE OF GRIPPING
 PALM GRIPPING HAND POSITION WITH A PISTOL
HANDLE IS MORE EFFICIENT THAN FINGER IN
RING GRASP
 IMPROPER GRIPPING CAUSES NEUROPRAXIA AND
COMPLICATIONS OF NERVE INJURY

41. Ergonomic handles…

42. MONITOR POSITIONING
 MISALIGNMENT OF EYE- HAND- TARGET AXIS
BECAUSE OF LIMITED FREEDOM IN MONITOR
POSITIONING IS RECOGNISED AS ERGONOMIC
DRAWBACK
 REALIGNMENT IMPROVES COMFORT, SAFETY
AND EFFICIENCY
 IN HORIZONTAL PLANE MONITOR SHOULD BE
STRAIGHT IN FRONT OF EACH PERSON AND
ALIGNED WITH A FOREARM- INSTRUMENT
MOTOR AXIS TO AVOID AXIAL ROTATION OF
SPINE

43. Visual Axis and Motor Axis

44.  IN SAGITTAL PLANE MONITOR SHOULD BE
POSITONED AT OR WITHIN 25 OPTIMAL DEGREES
BELOW THE HORIZONTAL PLANE OF THE EYE TO
AVOID NECK EXTENSION
 2ND MONITOR FOR ASSISTANT REDUCES STRAIN
ON CERVICAL SPINE
 MONITOR SHOULD BE PLACED 4-8 FT FROM
OPERATING SURGEON

45. Surgeon’s Stance
Ideal relaxed stature Tiring

46. Ergonomics
 Straight Line principle
 Triangulation
 Manipulation angle
 Elevation angle
 Low lying table
 Gaze down view

47. Straight Line Principle
Monitor
Surgeon
Pathology

48. Co Axial alignment

49. TROCAR PLACEMENT
 PORTS ARE PLACED IN PRINCIPLES OF
TRIANGULATION
 TARGET ORGAN SHOULD BE 15-20CM FROM
CENTRE PORT
 2 REMAINING TROCARS ARE PLACED IN THE
SAME 15-20CM ARC AT 5-7CM ON EITHER SIDE OF
THE OPTICAL TROCARS
 IF REQUIRED, 2 MORE PORTS CAN BE PLACED IN
THE SAME ARC
 IN SILS, TRIANGULATION IS ACHIEVED THROUGH
CURVED INSTRUMENTS

50. Ergonomics of Port Placement

51. Base Ball Diamond Concept
& Triangulation
S
C
R
L
P
MONITOR

52. Manipulation angle
Azimuth Angle
30-45 degree
Manipulation Angle
60-90 degree

53. Elevation angle

54. Ideal angles!
 1. Manipulatation angle: 60 degree
 2. Azimuth angle: Equal/30 degree each
 3. Elevation angle: 60 degree

55. SILS
SILS Ports
Experience
Energy Sources
Equipments
Co axial instruments
Endo eye laparoscope
Spider system

56. 360 degree rotation/Roticulation
Endo eye

57. Ergonomics with SILS
Spider System
Intra abdominal Triangulation

58. Da Vinci Robot
Wrist like action
Precision

59. Ideal Relaxed Position
-straight head, in the axis of the trunk,
without rotation or extension of the cervical
spine;
- shoulders in a relaxed and neutral position;
- arms alongside the body
- elbows bent to 70 to 90 degrees
- forearms in an horizontal or slightly
descending axis-
-hands pronated (physiological resting
position);
- hands and fingers lightly grip the
handles/handpiece
•Waist line table
•Gaze down view of monitor
•Straight line principle
•Triangulation

60. To be an efficient Surgeon…
 Concentrate on
 Equipments
 Environment

61. OT LAYOUT
 OT LAYOUT IS PLANNED ACCORDING TO PROCEDURE
 ALLOWS UNOBSTRUCTED MOVEMENT OF OT
PERSONNEL AND SURGEON
 FOOT PEDALS SHOULD BE EASY REACH AND IN AXIS
WITH OPERATING FORCE TO PREVENT TORSION OR
STRAIN ON FOOT
 SHOULD BE ADEQUATELY ELIMINATED TO PREVENT
STRAIN ON EYES
 CABLES AND WIRES SHOULD BE FLUSHED WITH THE
GROUND AND COVERED WITH INSULATED DUCT

62.  USE OF LAPAROSCOPY IS ASSOCIATED WITH
SIGNIFICANT ERGONOMIC PROBLEMS HENCE
PROPER TRAINING AND AWARENESS IS
ESSENTIAL THUS MAKING IT SAFER FOR BOTH
SURGEONS AND PATIENTS