1. INSTRUMENTS AND Pneumoperitoneum

2. 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

3. 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

4. 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

5. 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

6. Ralph V. Clayman, J of urol. Pg 1847. 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.

7. 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

8. Laparoscopic instruments

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

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

11. Entrapment bag LapSac

12. Entrapment bag Endobag (Tyco)

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

15. Nephrectomy

22. Flexible pyeloscopy for removal of caliceal stones using triradial graspers

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

24. 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. 2001 Mar

25. Auto suturing Accuracy (millimeters) The mean times (min:sec) --- 0.4575:08Conventional Laparoscopic suturing 0.6602:45EndoStitch (Tyco) 0.5082:40Suture Assist (Ethicon) Pattaras et al, J Endourol. 2001 Mar

26. 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

27. RESULTS: The average times in sec Tying with Quik-Stitch Extracorporeal knot tying Intracorporeal knot tying --- 67.7103.997.3The experienced surgeon 92.5224.3237.2The less experienced surgeons 128.7263.0265.3The least experienced Bermas et al, Journal of the Society of Laparoendoscopic Surgeons, 2004 Apr-Jun