INSTRUMENTS AND Pneumoperitoneum

Dr. Anmar Nassir, FRCS(C) Fellowship in Andrology (U of Ottawa) Fellowship in EndoUrology and Laparoscopy (McMaster Univ) Chairman, Department of Surgery Umm Al-Qura Univ Consultant Urology, King Faisal Specialist Hospital, Jeddah

There are 4 basic techniques used to create pneumoperitoneum: 1.blind Veress needle 2.direct trocar insertion 3.optical trocar insertion 4.open laparoscopy Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005

In 578 laparoscopic procedures: 1.blind insertion of the Veress needle (group 1, n = 301) 2.direct trocar insertion with elevation of the rectus sheath using 2 towel clips (group 2, n = 277). Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005

Results: Total complication rates: – gr 1 = 15.7% (n = 33) – gr 2 = 3.3% (n = 4) (P < 0.05) Conclusion: Direct trocar insertion with elevation of the rectus sheath using 2 towel clips is an easy, safe, and effective technique. Gu¨nenc et al. Surg Laparosc Endosc Percutan Tech, 2005

Ralph V. Clayman, J of urol. Pg Nov, 2005 Having been a Veress needle advocate throughout my career, I am loath to change. However, this scientifically well-done study gives me “pause”; quicker pneumoperitoneum with fewer complications is certainly a compelling argument for considering a change.

Longer OR time – In preparing or starting – Visualization – Instruments Telescopes from 1 mm diameter and 17.5 cm length up to 10 mm diameter and 42 cm length

Laparoscopic instruments

This reusable three-piece: Available in, 5 mm and 10 mm sizes, with lengths of 20 cm, 30 cm, 36 cm and 43 cm.

Clips & Staplers Endo-GIA stapler Clips Hem-o-lock

Entrapment bag LapSac

Entrapment bag Endobag (Tyco)

Instruments Summary Optics should be the state of art. Test function before use Familiarize staff with troubleshooting Think cost-effective

Nephrectomy

Flexible pyeloscopy for removal of caliceal stones using triradial graspers

The renal pelvis is sewn to the corresponding corner of the ureter (EndoStitch device shown).

Auto suturing 6 surgeons with laparoscopic experience were trained on the three suturing techniques. A pelvic trainer was set up with a freshly marked and incised swine renal pelvis and ureter 216 knots Knot was individually tested on a Monsanto Model 10 tensiometer (slippage, strength, and breakage points) Pattaras et al, J Endourol Mar

Auto suturing Accuracy (millimeters) The mean times (min:sec) :08Conventional Laparoscopic suturing :45EndoStitch (Tyco) :40Suture Assist (Ethicon) Pattaras et al, J Endourol Mar

Comparison b/w diff experience METHODS: 1) intracorporeal suturing and knot tying, 2) intracorporeal suturing and extracorporeal tying 3) mechanically assisted suture & pretied knot device (Quik-Stitch). 3 attending surgeons: 1 with much experience 2 with less experience 2 chief residents, with the least experience. Bermas et al, Journal of the Society of Laparoendoscopic Surgeons, 2004 Apr-Jun

RESULTS: The average times in sec Tying with Quik-Stitch Extracorporeal knot tying Intracorporeal knot tying The experienced surgeon The less experienced surgeons The least experienced Bermas et al, Journal of the Society of Laparoendoscopic Surgeons, 2004 Apr-Jun