Jan. 06, 2025
The journey of laparoscopy has evolved into single-incision and robotic surgery, driven by our desire to minimize operative morbidity. Since those initial steps, gynaecological surgery utilizing minimally invasive techniques has undergone rapid changes. With computerized design and microchip-controlled safety features, laparoscopic surgeons must rely on advanced equipment and grasp the electromechanical functions of these instruments. In this dynamic setting, understanding the characteristics of commonly used surgical tools is crucial. The basic equipment essential for any laparoendoscopic procedure typically includes an endoscope, camera, light source, video monitor, insufflator, trocars, and surgical instruments. However, various variants of each tool are available on the market.
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The discussion surrounding the cost-effectiveness of disposable versus reusable instruments is ongoing. The choice of instruments is influenced by factors such as function, reliability, and expense. Consequently, a combination of disposable and reusable instruments is commonly utilized in many laparoscopic procedures. Disposable trocars and scissors are frequently used, while reusable tools may include graspers, coagulation spatula/hooks, and needle drivers. Below, we describe the commonly used laparoscopic instruments.
Uterine manipulators are crucial for positioning the uterus and expanding the operating space. Several uterine manipulators are available, including the HUMI® (Cooper Surgical), RUMI® (Cooper Surgical), Spackman, Cohen, Hulka, Valtchev, Pelosi, and Clearview® (Endopath). Some are reusable, while others are designed for single use. Most manipulators feature a channel for chromotubation, although certain models, such as the Hulka tenaculum and Pelosi, lack this feature. The Clearview manipulator has the greatest anterior-posterior motion range at 210°, while Hulka tenaculum and the Spackman and Cohen manipulators have straight shafts that limit their motion and applicability in advanced laparoscopic procedures.
The Veress needle is specifically designed with a blunt-tipped, spring-loaded inner stylet and a sharp outer needle, employed to achieve pneumoperitoneum during closed laparoscopy. It is available in both disposable and reusable forms, typically measuring 12cm or 15cm in length.
Primary port insertion is often associated with injuries in minimally invasive surgery, leading to a persistent debate regarding the benefits of various entry techniques (open, closed, or direct entry). Current evidence does not support the superiority of any single technique in preventing major vascular or visceral complications, although closed entry presents a higher risk of unsuccessful insertion. The recent Cochrane review indicated a lower risk of vascular injury with direct entry compared to using a Veress needle.
Trocars are employed to create small passageways through the abdominal wall and come in various textures. Both disposable and reusable trocars are available in different sizes, sharing several common components:
Laparoscopes come in sizes ranging from 2mm to 12mm, with the 10mm size being the most commonly used in gynaecology. Similar to hysteroscopes, laparoscopes may have different viewing angles, such as 0°, 30°, or 45°. The 0° telescope, offering a forward view, is favored by many gynaecologists, particularly if a less experienced assistant is present. The 30° scope can be rotated to increase the field of view, while the 45° scope is useful for single-incision laparoscopies, though it is less common. Each laparoscope has a number engraved near the eyepiece indicating the viewing angle.
The typical diameter for laparoscopic instruments is 5mm, although sizes range from 2mm to 12mm. Instruments with diameters less than 5mm offer decreased shaft rigidity, making them more flexible but also more fragile. The standard length for these instruments ranges from 34cm to 37cm, with 45cm-long instruments being advantageous for bariatric patients or single-site laparoscopies.
Most laparoscopic instruments have four degrees of freedom of movement: in/out, up/down, left/right, and rotation. Certain devices, known as articulating or roticulating instruments, offer angulation at their tips, which is particularly beneficial for achieving triangulation during single-incision laparoscopy.
Graspers and scissors typically possess an insulated sheath, a central working device, a handle, and rotating capability at the working end.
Ringed handles resemble the conventional ring handle found on most needle holders in open surgery, and may be aligned or directed 90° relative to the working axis. Other handle types include:
Different ratchet types provide locking mechanisms for the handles.
Scissors with curved tips, similar to Metzenbaum scissors, are commonly utilized. Many endoscopic scissors can also connect to electrosurgical units, and they are available in a range of tips.
Grasper jaws can be classified as single action (one fixed, one articulated jaw) or double action (both jaws articulated). Single-action jaws exert a stronger closing force, ideal for needle drivers, while double-action jaws open wider for dissection tasks. Variants of graspers exist, with inner jaw surfaces tailored to specific uses:
Laparoscopic tenacula are also available with single-toothed and double-toothed jaws.
Numerous styles of needle drivers exist, with selection largely dependent on surgeon preference. Jaws may be curved or straight, typically having flat or finely serrated surfaces to grasp needles effectively. Certain needle holders, termed self-righting, feature dome-shaped indentations in their jaws to automatically orient needles perpendicularly for easier grasping. However, this indentation might complicate loading the needle at an oblique angle. Needle drivers also come with various handle types (finger grip, palm grip, pistol grip).
Myoma screws, resembling probes with corkscrew tips, are frequently utilized during myomectomies.
The suction irrigator serves multiple functions. Most utilize a trumpet valve, though some have sliding valves. The irrigation system may operate via pressure bags or pumps. Care should be exercised to gently release attached tissues such as omentum, fallopian tubes, or bowel when using suction probes.
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The aspiration needle is a 16/22-gauge needle, utilized for aspirating and injecting fluids.
Two types of knot pushers are available: closed-end and open-end, each with its unique advantages and disadvantages.
Energy devices include monopolar, bipolar, advanced bipolar, harmonic, combined, and morcellator devices. Monopolar devices are frequently employed in endometriosis resections and for incising the vaginal cuff during laparoscopic hysterectomies. A variety of monopolar hooks and spatulae are available, and most scissors have attachments for connecting mono-polar leads.
Bipolar devices transmit continuous waveform electrical currents through the jaws of forceps, minimizing the risk of damage to surrounding tissues while achieving tissue sealing and hemostasis through thermal coagulation without the capacity to cut. The classic bipolar device is the Kleppinger bipolar forceps. Various bipolar devices, often in the form of graspers, are now available.
The evolution of energy devices, particularly those with advanced bipolar features, has been pivotal in the exponential growth of laparoscopic surgery. The increasing popularity of these devices is reflected in their occasional application in open and vaginal surgeries.
Bipolar devices like LigaSure®, Gyrus PKS®, and EnSeal® achieve hemostasis for vessels up to 7mm. They deliver low voltage with impedance-based feedback, regulating energy and tissue temperatures below 100°C. This bipolar energy denatures the collagen and elastin in vessel walls, with tissue apposition and pressure sealing the vessel walls—a process known as coaptive coagulation. Compared to traditional bipolar instruments, these devices exhibit reduced thermal spread, charring, and sticking. However, some require specialized electrosurgical units and can be quite costly.
LigaSure (Covidien) utilizes a continuous bipolar waveform with an integrated cutting mechanism. GyrusPK (Gyrus ACMI) delivers a pulsed bipolar waveform allowing tissue and device tips to cool during the energy-off phase but lacks a cutting feature. Enseal (Ethicon) employs nanometer-sized conductive particles to direct energy and control temperatures between the jaws. Similar to LigaSure, it is multifunctional, featuring an I-Blade® to cut sealed tissue.
Harmonic devices contain a piezoelectric crystal in the handpiece that converts electrical energy into ultrasonic energy, which vibrates the active blade at the tip at 55,000Hz. This energy mechanically cuts while providing a degree of collateral thermal coagulation for hemostasis, without active current flowing in the tissue. The advantages of harmonic devices include lower operational temperatures (<80°C), resulting in reduced thermal spread and charring. The mechanical vibrations vaporize intercellular water at lower temperatures, aiding in tissue dissection. They are FDA-approved for sealing vessels smaller than 5mm. Although harmonic devices maintain low temperatures, their active blades can become very hot and retain heat, necessitating caution to avoid contact with vital structures shortly after activation.
Thunderbeat® (Olympus) integrates advanced bipolar energy and ultrasonic energy in a single, multifunctional, hand-activated instrument, potentially reducing surgical time.
Morcellators play a critical role in removing specimens during procedures like myomectomies when large tissue amounts are retrieved laparoscopically. These devices come in various types, with a key safety guideline emphasizing keeping the morcellator tip close to the abdominal wall to gently pull tissue into the device rather than pushing it into the tissue. Morcellators typically require ports larger than 5mm. Recent FDA communications on morcellation safety led to revised guidelines and a joint statement from AGES and RANZCOG. To prevent tissue dissemination, power morcellation in an isolation bag has been recommended. A new in-bag morcellation device, the Alexis® Contained Extraction System, is now available.
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