Handbook of Laparoscopy Instruments

Ergonomics studies aptly fitting a worker to his job or how the environment is more conducive to a laparoscopic surgeon. In 1949, the phrase was fully defined and benefited and protected many aspects of human activity [1]. In the context of laparoscopy, the importance of ergonomics cannot be overstated. Suturing time can be reduced by using proper ergonomics, according to studies [2]. Ergonomically designed items have been found to alleviate pressure-related chronic discomfort in surgeons [3]. This article discusses fundamental principles and procedures such as triangulation, ideal coaxial alignment, doctor-patient drawbacks, and how to forego these challenges with recent technological breakthroughs. 

Laparoscopic instruments should be sterilized by high-level disinfection (H.L.D.). Sterilization is any process that removes or kills all microbial organisms, such as fungi, bacteria, viruses, spore forms, etc., present on a surface, contained in a fluid, or a compound such as biological culture media. Sterilization can be achieved by applying heat, chemicals, and irradiation; high-pressure sterilization is a process that destroys or eliminates all forms of microorganisms. Disinfection is a process that eliminates many or all pathogenic microorganisms, except bacterial spores, on inanimate objects. Decontamination is the removal of all pathogenic microorganisms from objects to make them safe to handle / use/ discard.

The surgical theatre is a vital and intricate setting where time and resources are typically limited. Laparoscopic surgical procedures demand specific technical and analytical skills from operating room personnel, as there is a high chance of mistakes leading to potentially fatal repercussions in laparoscopic surgery [1]. The acquisition of complete, precise, and appropriate knowledge about linkage and interaction between human beings and laparoscopic equipment in operation theatre must be considered of utmost importance. To avoid difficulties during surgery, a surgeon must become familiar with this equipment and instruments [2].

Optical devices in laparoscopic surgery comprised a telescope (0-30-45 degree telescopes), a light source, a light cable, a camera, and a monitor. All play an essential role from the beginning to the end of the procedure. The outcome of a suitable laparoscopic procedure depends on optical devices. The telescope used may have 0-3-45 degree view. The light source can be Helium or xenon. Xenon is costly but resembles natural light more, giving a good in vivo view.

Optical fibers carry light into the abdomen, and the rod lens mechanism moves images to the camera and then to monitor, to result in a successful procedure.

This chapter will go through the mechanism and working of light cables, cameras and light sources used in laparoscopy

Creating and maintaining a pneumoperitoneum is a vital laparoscopy procedure. A set of instruments, including an insufflator, are used to achieve pneumoperitoneum. Despite having a critical role in laparoscopy, it is the least understood of all laparoscopic devices and appliances. Co2 insufflator, also known as an endoflator, and laproflator is the most intelligent laparoscopy device as it has to work under control, considering physiology. In addition, gas cylinders, connector tubing, dual valves and gas tubing are also utilized for creating pneumoperitoneum.

Laparoscopy has emerged as a spin-off to technological advancement in the field of general surgery that not only aims to minimize the operative trauma to the patient but also to consummate the surgical endpoint. It has succeeded in curtailing the length of scars over the patient thus being able to bring less disfigurement to the patient. It has proven frugal to the patients as it reduces the operative period, and stay in the hospital and eases comparatively early resumption of the work. It has taken the edge off the psychological trauma the patient undergoes, thus adding to better surgical outputs. The long learning curve and the intraoperative complications including bleeding have proven arduous but the adoption of new technology has succeeded to master these complications. 

Operative hand instruments play a pivotal role in Laparoscopic surgeries. They are either disposable or reusable. Most instruments are made up of three parts mainly; Handle, Outer covering sheath and working insert. Instruments are broadly categorized based on the type of dissection they are used for. Instruments for Blunt dissection are Graspers and dissectors. Graspers can be of traumatic or atraumatic variety. Bipolar and Maryland are the two essential dissectors used widely. Instruments used for sharp dissection are scissors, knives, needle holders, coagulation devices, electrosurgery hooks and a spatula. All the reusable instruments have to be sterilized before each use. A few instruments have to be dissembled before sterilizing. Hence, basic knowledge regarding the various instruments is vital for a laparoscopic surgeon to operate flawlessly

In ancient times, a hot iron rod was used for charring at the bleeding site to stop bleeding. The earliest significant contribution to a sophisticated method of generating heat to cauterize tissue from electrical current is by Bovie. Energy sources are classified as radiofrequency electrosurgery, laser, ultrasonic, and argon beam coagulation. The majority (85%) of surgeons use monopolar electrosurgery. The electrosurgical effect on the tissue causes cutting, coagulation, fulguration, and desiccation. It uses ultrasonic technology, the unique energy form that allows both cutting and clotting at the precise point of impact, resulting in minimal lateral thermal tissue damage. Cutting and coagulation are done at lower temperatures than those used by electrosurgery or lasers. The Harmonic Scalpel has five power levels. Increasing the power level increases cutting speed and decreases coagulation.

In contrast, less power reduces cutting speed and increases clotting. Argon-enhanced electrosurgery incorporates a stream of argon gas to improve the surgical effectiveness of the electrosurgical current. Argon gas is inert and non-combustible, making it a safe medium to pass electrosurgical current.

Early endoscope was developed about 50 years ago. It was initially developed as a diagnostic tool. Since then, several modifications in endoscopes have been made with many developments in endoscopic accessories. In the current era, endoscopy is used for both diagnostic and therapeutic procedures. Endoscopic accessories are essential tools for therapeutic endoscopic procedures. Endoscopic accessories are specially designed devices that pass through accessory channel of the endoscope & therapeutic endoscopic procedures. Routinely encountered endoscopic endoscopy needs commonly available endoscopic accessories. Common clinical problems in day to day practice are gastrointestinal tract bleeding, gastrointestinal tract foreign bodies, gastrointestinal tract strictures and the requirement of enteral access for enteral feeding. These procedures can be carried out in a day-to-day practice after gaining adequate experience and knowledge about the procedures. Commonly used endoscopic accessories can be divided into hemostatic devices, foreign Body (FB) removal devices, feeding tubes, biopsy forceps and dilators. Hemostatic devices are endoscopic accessories to control bleeding from the GI tract. Bleeding from the GI tract may be of variceal or non-variceal origin and accordingly different devices may be required. Various types of foreign body ingested can be encountered during clinical practice which can be dealt with different endoscopic accessories. Enteral feeding is a safe, effective and physiological means of providing enteral nutrition. Depending on the clinical situation, gastric or naso-jejunal enteral access may be required for enteral nutrition. Feeding tubes can be placed endoscopically for enteral access. Different types of feeding tubes are available. Biopsy forceps are tissue acquisition devices for diagnostic purposes. 

Primarily, it is a computer-assisted surgery. It's a modified future of minimally invasive surgery. With this method, the surgeon makes decisions and gives commands, and a robot carries out the surgery. The main advantage of robotic or minimally invasive surgery is that instead of operating patients through large incisions, patients get operated on through small incisions with less trauma to the tissue. There is less pain and a shorter hospital stay with an early return to work.