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Laparoscopic Instruments

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Presentation on theme: "Laparoscopic Instruments"— 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 Monopolar energy is the most preferred in 74%.
BJU 2005 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.

17 Standard Techniques Newer Technology 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 The mechanism for monopolar energy-based surgical injuries is either from direct leakage of current flowing through defects in active-electrode insulation, or by capacitive leakage of current originating from the shaft of the active electrode. Capacitive monopolar current leakage is particularly worrisome with laparoscopic procedures, as the injury will most commonly occur outside the surgeon’s field of vision and might go unrecognized. In a study in 1994, the Physician Insurers Association of America found that during three-quarters of cases in which laparoscopic injury occurred, the injury was not recognized before the end of the procedure. The risk of surgical complications is inextricably linked to the surgeon’s fundamental knowledge of instrumentation, surgical technique, applicable biophysics, and relevant anatomy. It is incumbent upon surgeons of all specialities to understand the devices in daily Use.

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

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22 The Harmonic Scalpel Mechanical energy Electrical energy
Piezo-electric crystals in the hand-piece become excited.Disk transfers electrical energy into mechanical energy. Mechanical energy Electrical energy

23 The Harmonic Scalpel Blade vibrates at 55,000/sec 50o C 100o C
Blade extender Silicon nodes Protein coagulation Piezo-electric crystals in the hand-piece become excited.Disk transfers electrical energy into mechanical energy. Blade vibrates at 55,000/sec 50o C 100o C Proteins Disorganise to form a coagulum

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

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

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

27 The Harmonic Scalpel: Technique

28 The Harmonic Scalpel: Technique

29 The Harmonic Scalpel: Technique

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 Collagen-elastin seal:
Kennedy JS: Surg Endosc 1998

33 Bipolar: Ligasure 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.

34 Kennedy JS: Surg Endosc 1998

35 Mean burst pressure(mmHg) by device
EBVS (Ligasure) 128 601 442 UCS (Harmonic) 226 205 175 Plastic clip 737 854 767 Ti clip 757 593 628 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 Bipolar: Gyrus Plasmakinetic system
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.

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

40 Ligasure Vs Gyrus PK (Bursting pressure)
Vessel size Ligasure (mm Hg) Gyrus PK (mm Hg) 2-3 mm 326 397 4-5 mm 573 389 6-7 mm 585 317 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 Ligasure instruments create a wider seal
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 Harmonic ACE ENSEAL Gyrus PK

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


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