laparoscopic instruments dr deepak dubey, manipal hospital, bangalore
TRANSCRIPT
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Laparoscopic Instruments
Dr Deepak Dubey, Manipal Hospital, Bangalore
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Light Source
• Consists of • Lamp• Heat Filter• Condensing lens• Manual or automatic intensity
control circuit
• LAMPS• Quartz Halogen- Electrodes of
Tungsten• Incandescent Bulbs• Xenon
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Laparoflator
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Light Cable (Fiber optic)
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Laparoscopic Instruments
• Discovered by a Hungarian Internist Janos Veress in 1932 for collapsing infected lung in TB patients
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Port Closure needle (Carter –Thomason) needle
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Laparoscopic Bull Dog Clamps
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Laparoscopic Satinsky Clamp
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Hemolok (Weck) Clips
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Harmonic Scalpel
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Enseal
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Coagulation and Cutting devices in Laparoscopic Urology
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• 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
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Standard Techniques
• Electrosurgical- Monoploar• Electrosurgical- Bipolar
• Ultracision- Harmonic scalpel• Vessel sealing system- Ligasure
Newer Technology
• Gyrus-ACMI plasmakinetic trisector• Enseal- nanotechnology• Starion sealing system.
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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
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Conventional Bipolar Cautery
• Coagulates vessels upto 7 mm• Stray Energy
• Blackening of Tissue• Insulation Failure
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The Harmonic Scalpel
Electrical energyMechanical energy
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The Harmonic Scalpel
Silicon nodesBlade extender
Blade vibrates at 55,000/sec
Protein coagulation
Proteins Disorganise to form a coagulum
50o C 100o C
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Harmonic Scalpel : Tissue effects
Amaral JF, Chrostek CA .SAGES, 1995
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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
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The Harmonic Scalpel: Technique
• Tissue tension• Blade sharpness• Time• Power level• Grip force
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The Harmonic Scalpel: Technique
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The Harmonic Scalpel: Technique
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The Harmonic Scalpel: Technique
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Bipolar: Ligasure
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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
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Kennedy JS: Surg Endosc 1998
Collagen-elastin seal:
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• 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
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Kennedy JS: Surg Endosc 1998
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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
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FDA approval
• ultrasonic energy for vessels up to 3 mm• EBVS (elctrothermal bipolar vessel sealer)
for vessels up to 7 mm
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Extent of thermal injury by device
• EBSV (Ligasure)• 2-3 mm
• Ultrasonic scalpel (Harmonic)• 0-1 mm
Landman J et al., J Urol, 2003
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• 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
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• Utilises a nanotechnology feedback system wherein the temperature is adjusted by feedback from the nanoparticles in the device.
• Minimises lateral thermal spread.
Bipolar: Enseal
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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
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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.
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Mean Burst Pressure
Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.
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Mean smoke/vapor production
Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.
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Mean Tmax at 2 mm laterally
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• 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
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• Its the Magician not the Wand who creates the Magic!!