Laparoscopic Instruments Dr Deepak Dubey, Manipal Hospital, Bangalore

Laparoscopic Instruments

Dr Deepak Dubey, Manipal Hospital, Bangalore

Light Source

• Consists of • Lamp• Heat Filter• Condensing lens• Manual or automatic intensity

control circuit

• LAMPS• Quartz Halogen- Electrodes of

Tungsten• Incandescent Bulbs• Xenon

Laparoflator

Light Cable (Fiber optic)

Laparoscopic Instruments

• Discovered by a Hungarian Internist Janos Veress in 1932 for collapsing infected lung in TB patients

Port Closure needle (Carter –Thomason) needle

Laparoscopic Bull Dog Clamps

Laparoscopic Satinsky Clamp

Hemolok (Weck) Clips

Harmonic Scalpel

Enseal

Coagulation and Cutting devices in Laparoscopic Urology

• 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

Standard Techniques

• Electrosurgical- Monoploar• Electrosurgical- Bipolar

• Ultracision- Harmonic scalpel• Vessel sealing system- Ligasure

Newer Technology

• Gyrus-ACMI plasmakinetic trisector• Enseal- nanotechnology• Starion sealing system.

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

Conventional Bipolar Cautery

• Coagulates vessels upto 7 mm• Stray Energy

• Blackening of Tissue• Insulation Failure

The Harmonic Scalpel

Electrical energyMechanical energy

The Harmonic Scalpel

Silicon nodesBlade extender

Blade vibrates at 55,000/sec

Protein coagulation

Proteins Disorganise to form a coagulum

50o C 100o C

Harmonic Scalpel : Tissue effects

Amaral JF, Chrostek CA .SAGES, 1995

Harmonic 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

YES NO

Minimal lateral spread and tissue damage YES NO

No charring, dessication and tissue sticking YES NO

Reduces smoke, mist or vapor for improved visibility

YES NO

Harmonic Vs Electrocautery

The Harmonic Scalpel: Technique

• Tissue tension• Blade sharpness• Time• Power level• Grip force

The Harmonic Scalpel: Technique

The Harmonic Scalpel: Technique

The Harmonic Scalpel: Technique

Bipolar: Ligasure

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

Kennedy JS: Surg Endosc 1998

Collagen-elastin seal:

• 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

Kennedy JS: Surg Endosc 1998

Mean burst pressure(mmHg) by device

Device 2-3mm 4-5mm 6-7mm

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

FDA approval

• ultrasonic energy for vessels up to 3 mm• EBVS (elctrothermal bipolar vessel sealer)

for vessels up to 7 mm

Extent of thermal injury by device

• EBSV (Ligasure)• 2-3 mm

• Ultrasonic scalpel (Harmonic)• 0-1 mm

Landman J et al., J Urol, 2003

• 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

• Utilises a nanotechnology feedback system wherein the temperature is adjusted by feedback from the nanoparticles in the device.

• Minimises lateral thermal spread.

Bipolar: Enseal

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

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.

Mean Burst Pressure

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

Mean smoke/vapor production

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

Mean Tmax at 2 mm laterally

• 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

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