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Laparoscopic Instruments Dr Deepak Dubey, Manipal Hospital, Bangalore.

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Presentation on theme: "Laparoscopic Instruments Dr Deepak Dubey, Manipal Hospital, Bangalore."— Presentation transcript:

1 Laparoscopic Instruments Dr Deepak Dubey, Manipal Hospital, Bangalore

2 Light Source Consists of Lamp Heat Filter Condensing lens Manual or automatic intensity control circuit LAMPS Quartz Halogen- Electrodes of Tungsten Incandescent Bulbs Xenon

3 Laparoflator

4 Light Cable (Fiber optic)

5 Laparoscopic Instruments Discovered by a Hungarian Internist Janos Veress in 1932 for collapsing infected lung in TB patients

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7 Port Closure needle (Carter – Thomason) needle

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10 Laparoscopic Bull Dog Clamps

11 Laparoscopic Satinsky Clamp

12 Hemolok (Weck) Clips

13 Harmonic Scalpel

14 Enseal

15 Coagulation and Cutting devices in Laparoscopic Urology

16 Overall score 41%. Monopolar energy is the most preferred in 74%. Monopolar energy is used by >85% for laparoscopic procedures. Emergency Care Research Institute (ECRI): the rapid increase of laparoscopy has created simultaneous increase in injuries from ESI. BJU 2005

17 Standard Techniques Electrosurgical- Monoploar Electrosurgical- Bipolar Ultracision- Harmonic scalpel Vessel sealing system- Ligasure Newer Technology Gyrus-ACMI plasmakinetic trisector Enseal- nanotechnology Starion sealing system.

18 Monopolar cautery. Monopolar Electrosurgical Coagulates vessels upto 2 mm Current leaks, insulation breaks. Capacitative coupling. Contact with other conducting instruments Thermal spread to vital structures Charring of tissue smoke

19 Conventional Bipolar Cautery Coagulates vessels upto 7 mm Stray Energy Blackening of Tissue Insulation Failure

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22 The Harmonic Scalpel Electrical energyMechanical energy

23 The Harmonic Scalpel Silicon nodesBlade extender Blade vibrates at 55,000/sec Protein coagulation Proteins Disorganise to form a coagulum 50 o C100 o C

24 Harmonic Scalpel : Tissue effects Amaral JF, Chrostek CA.SAGES, 1995

25 HarmonicElectrocautery Simultaneously cuts and coagulates soft tissue and vessels AND seals lymphatics YESNO Lower temperatures on tissue (50 o C-100 o C vs 150 o C to 400 o C YESNO Minimal lateral spread and tissue damageYESNO No charring, dessication and tissue stickingYESNO Reduces smoke, mist or vapor for improved visibility YESNO Harmonic Vs Electrocautery

26 The Harmonic Scalpel: Technique Tissue tension Blade sharpness Time Power level Grip force

27 The Harmonic Scalpel: Technique

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30 Bipolar: Ligasure

31 Conventional bipolar vs. modern technique feedback-controlled bipolar vessel sealing high current, low voltage pulsating energy cooling intervals simultaneous compression applied instruments measure the current between jaws during coagulation minimal thermal spread sealing effect denaturation of collagen and elastin fibers no thrombus formation

32 Kennedy JS: Surg Endosc 1998 Collagen-elastin seal:

33 Permanently fuses vessels upto and including 7 mm in diameter Unique combination of pressure and energy to create vessel fusion. Feedback-controlled system automatically discontinues energy when seal cycle is complete. Bipolar: Ligasure

34 Kennedy JS: Surg Endosc 1998

35 Mean burst pressure(mmHg) by device Device2-3mm4-5mm6-7mm EBVS (Ligasure) UCS(Harmonic) Plastic clip Ti clip Harold KL et al., Surg Endosc 2003

36 FDA approval ultrasonic energy for vessels up to 3 mm EBVS (elctrothermal bipolar vessel sealer) for vessels up to 7 mm

37 Extent of thermal injury by device EBSV (Ligasure) 2-3 mm Ultrasonic scalpel (Harmonic) 0-1 mm Landman J et al., J Urol, 2003

38 Plasmacision leverages the electrically conductive properties of tissue fluid to form a tightly defined low-temperature plasma field. In Plasmacision cut phase, the plasma corona precisely divides tissue. In bipolar coag phase the Plasma knife tip delivers controlled RF to elevate tissue temeperature, dessicating and sealing blod vessels. Bipolar: Gyrus Plasmakinetic system

39 Utilises a nanotechnology feedback system wherein the temperature is adjusted by feedback from the nanoparticles in the device. Minimises lateral thermal spread. Bipolar: Enseal

40 Ligasure Vs Gyrus PK (Bursting pressure) Vessel sizeLigasure (mm Hg)Gyrus PK (mm Hg) 2-3 mm mm mm Carbonnel 2003, J Laparoendosc Adv Surg Tech A;16(6):377

41 Mean time to SEAL Comparison of devices to seal 5 mm bovine arteries Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.

42 Mean Burst Pressure Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.

43 Mean smoke/vapor production Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.

44 Mean Tmax at 2 mm laterally

45 All four instruments efficacious and safe in sealing and cutting blood vessels All instruments created good seals with supraphysiologic bursting pressures Enseal highest bursting pressure, however even lowest bursting pressures were in supraphysiologic range Ligasure instruments create a wider seal Heating higher with Harmonic ACE Ligasure Harmonic ACE ENSEAL Gyrus PK

46 Its the Magician not the Wand who creates the Magic!!


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