INSTRUMENTS AND Pneumoperitoneum

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INSTRUMENTSANDPneumoperitoneum
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• 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

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• There are 4 basic techniques used to create
  pneumoperitoneum
• blind Veress needle
• direct trocar insertion
• optical trocar insertion
• open laparoscopy

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

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

Gunenc et al. Surg Laparosc Endosc Percutan
Tech, 2005
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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.

• Ralph V. Clayman,

J of urol. Pg 1847. Nov, 2005
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Telescopes from 1 mm diameter and 17.5 cm length
up to 10 mm diameter and 42 cm length

• Longer OR time
• In preparing or starting
• Visualization
• Instruments

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• Laparoscopic instruments

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

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Clips Staplers

• Endo-GIA stapler
• Clips
• Hem-o-lock

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Entrapment bag

• LapSac

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Entrapment bag

• Endobag (Tyco)

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Instruments Summary

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

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Nephrectomy
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• Flexible pyeloscopy for removal of caliceal
  stones using triradial graspers

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

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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
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Auto suturing
Accuracy (millimeters) The mean times (minsec) ---
0.457 508 Conventional Laparoscopic suturing
0.660 245 EndoStitch (Tyco)
0.508 240 Suture Assist (Ethicon)
Pattaras et al, J Endourol. 2001 Mar
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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
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RESULTS

• The average times in sec

Tying with Quik-Stitch Extracorporeal knot tying Intracorporeal knot tying ---
67.7 103.9 97.3 The experienced surgeon
92.5 224.3 237.2 The less experienced surgeons
128.7 263.0 265.3 The least experienced
Bermas et al, Journal of the Society of
Laparoendoscopic Surgeons, 2004 Apr-Jun