12 Laparoscopic Instrumentation

Monish Aron, Mihir M. Desai, Mauricio Rubinstein, Inderbir S. Gill

Contents Laparoscopic Instrumentation Introduction 271 Laparoscopic Instrumentation 271 Instruments for Laparoscopic Access Instruments for Laparoscopic Access 271 Transperitoneal Access 271 Transperitoneal Access Retroperitoneal Access 273 Laparoscopic Trocars 274 Closed Access Using the Veress Needle. In the closed Types of Trocars 274 approach, a Veress needle (Fig. 1) is initially placed Sites for Trocar Placement 274 percutaneously into the peritoneal cavity, usually Trocar Insertion Technique 274 through one ofthe port sites [1]. The standard Veress Grasping Instruments 275 Cutting Instruments 275 needle is a metallic needle with a retractable protec- Energy Sources for Laparoscopic Surgery 275 tive blunt tip. The blunt tip retracts when the tip of Clips and Staplers 276 the Veress needle is pressed against a tough structure Suturing and Knot Tying 278 such as fascia, thus exposing the sharp edge of the Glues, Bioadhesives and Hemostatic Agents 279 needle. Once the needle passes through the layers of Aspiration and Irrigation Instruments 279 the abdominal wall and enters the peritoneal cavity, Instrumentation for Port Site Closure 280 the blunt tip is deployed, thereby protecting the ab- Insufflant System 280 Visualization System 280 dominal viscera from injury from the sharp tip. The Operating Room Setup 281 cannula is hollow, allowing for initial peritoneal insuf- Patient Positioning and Draping 282 flation. Placement of Operative Team and Equipment 283 The Veress needle is available as a disposable or a Conclusion 284 reusable instrument. Certain modified Veress needle- References 284 type devices are available. One such device is the 2-mm Minisite (USSC, Norwalk, CT) port, which is Introduction the author's instrument ofpreference forobtaining closed peritoneal access. The Minisite has a retractable Laparoscopic surgery, reconstructive and ablative, is tip similar to the Veress needle, and can also be used being increasingly applied in the treatment ofa vari- as a 2-mm cannula by removing the inner trocar nee- ety ofbenign and malignant conditions affecting the dle. In cases where the correct position ofthe needle urinary tract. Improvements in instrumentation and is questionable, a 1.9/2.0-mm telescope can be passed technology have played a pivotal role in the expanding through the Minisite cannula to assess its position. applications oflaparoscopic and minimally invasive For pelvic laparoscopic procedures, the patient is surgery. This chapter will highlight the fundamental usually supine and the Veress needle is placed through and practical aspects oflaparoscopic instrumentation a subumbilical incision. The bladder is emptied and common to most laparoscopic urological procedures. the patient is placed in a Trendelenburg tilt. The needle is directed towards the pelvis in order to avoid injury to the great vessels. For upper tract laparoscopic procedures on the kidney and adrenal, the patient is generally in the flank position, and the Veress needle 272 M. Aron

Fig. 1. Photograph of a Veress needle. We prefer to obtain transperitoneal access using a Veress needle in most uncompli- catedlaparoscopic procedures

is placed through the iliac fossa in order to avoid in- primary access is obtained through a 2.5-cm incision advertent injury to the bowel, which typically gravi- made at one ofthe port sites. The incision is carried tates medially. In all instances, it is preferable to avoid down through the various abdominal wall layers to a Veress needle puncture in the vicinity ofa previous reach the peritoneum. The peritoneum is then grasped abdominal scar. The tactile sensation ofthe Veress between hemostats and opened sharply. The finger is needle passing through the various layers ofthe ab- introduced through the peritoneal opening to confirm dominal wall is extremely important. Typically one presence within the peritoneal cavity. has two distinct sensations ofgiving way at the level With the open access system, obtaining an air-tight ofthe external oblique/rectus fascia,and at the level seal at the site ofentry through the abdominal wall in ofthe transversalis fascia/peritoneum. The Veress nee- order to minimize insufflant leakage, is of critical im- dle is aspirated to rule out presence ofblood or bowel portance. A Hasson cannula may be used for this pur- content. The correct placement ofthe needle is con- pose (Fig. 2). The Hasson blunt-tip cannula is inserted firmed by injecting a few drops of saline and demon- into the peritoneal cavity and secured in place with strating the rapid drop ofmeniscus. Final confirma- fascial sutures. The authors prefer to use a blunt-tip tion is obtained by documenting a low intra-abdom- balloon cannula in lieu ofthe Hasson cannula since, inal pressure after initiating insufflation at a low flow in our opinion, the seal provided by the balloon port (1 l/min). Once the correct intra-abdominal pressure is better. has been confirmed, the insufflation flow rate can be maximally increased. Once the abdomen has been insufflated adequately (intra-abdominal pressure 15± 20 mmHg), the primary trocar is placed. The authors prefer to initially insufflate the abdomen up to 20 mmHg prior to inserting the first port. This keeps the abdomen tense and reduces the chances ofvisceral injury during the initial blind trocar placement. An- other technical caveat is to make a generous skin incision for the initial port site so as to reduce the grip- ping ofthe skin on the trocar. Additional trocars are subsequently inserted under laparoscopic visualization, thereby minimizing the risk ofinadvertent visceral or vascular injury. The closed approach for obtaining transperitoneal access has been criticized as being blind and having greater risk for inadvertent injury to the intraperitoneal contents. We believe that if proper care is taken, the risk with the closed approach is minimal.

Open Access Using the Hasson Technique. Many Fig. 2. The Hasson cannula has a cone at its proximal end surgeons prefer the open Hasson approach to obtain that can be securedto the fascia with sutures to providean initial transperitoneal laparoscopic access [2]. Here, air-tight seal after obtaining open access a 12 Laparoscopic Instrumentation 273

Retroperitoneal Access which allows optimal positioning in the retroperitoneum. Second, the balloon dilator has a transparent Retroperitoneal access is typically obtained by an cannula through which a 10-mm laparoscope can be open technique [3]. The primary incision is placed be- introduced to confirm proper positioning. Identifica- low the tip ofthe 12th rib. The skin, subcutaneous tis- tion ofthe psoas muscle inferiorly and the perineph- sue and external oblique fascia are incised sharply. ric fat superiorly confirms the correct balloon position The fibers of the internal oblique and transverses are between the kidney and the posterior abdominal wall. separated bluntly with the index finger up to the level Occasionally, other retroperitoneal structures such as ofthe thoracolumbar fascia, which is divided sharply ureter, gonadal vein, inferior vena cava, etc. may be to gain entry into the retroperitoneal space. The cor- identified through the balloon. Third, since the bal- rect position within the retroperitoneum is confirmed loon lies entirely in the retroperitoneum, inflating the by palpating the psoas muscle posteriorly and the balloon does not widen the initial incision made lower pole ofthe kidney superiorly. Initially, the retro- through the skin and abdominal wall. The balloon di- peritoneal space is developed with the help ofthe fin- lator is incrementally inflated up to 800 cc (each ger. A variety ofdevices have been used forfurther pump delivers approximately 20 cc air). The balloon is rapid development ofthe working space during retro- deflated and additional upper and/or lower retroperi- peritoneoscopy. Simple contraptions such as rubber toneal inflations may be performed as per the individ- catheters attached to a latex glove or condom, though ual procedure and pathology. inexpensive, in our opinion are not very efficient. We The balloon dilator is removed and a 10-mm blunt- prefer to balloon dilate the retroperitoneal space using tip balloon trocar (USSC) is inserted through the inci- the PDB balloon dilator (USSC), for several reasons sion (Fig. 4). The balloon port provides optimal seal- (Fig. 3). First, the balloon dilator has a rigid shaft ing ofthe abdominal wall, thereby minimizing leak of

Fig. 3. We prefer the PDB balloon dilator to rapidly and atraumatically create retroperitoneal working space for reasons spe- cifiedin the text. The balloon usedfor upper tract retroperitoneal laparoscopy is spherical andone pump deliversapproxi- mately 20 cc of air in the balloon. The balloon has a maximal capacity of 1,000 cc

Fig. 4. We prefer the 10-mm blunt-tip balloon trocar for use after open access either transperitoneal or retroperitoneal. This trocar provides an optimal air-tight seal when the abdominal wall is cinched between the external sponge andthe in- flatedballoon 274 M. Aron

CO2 and subcutaneous emphysema. This is ofcritical rect trocar placement. The primary camera port importance, given the already limited working space should be ideally in line with the structure ofinterest in the retroperitoneum [4]. (for example, renal hilum during laparoscopic nephrectomy), and should be approximately at a 458 an- Laparoscopic Trocars gle to the area ofinterest. The working ports (right and left hand) should be on either side of and at an Types of Trocars adequate distance from the primary camera port. Such a trocar arrangement leads to optimal orientation and The various types oftrocars currently used are shown maximum mobility ofthe working laparoscopic in- in Fig. 5. Trocars are either disposable or reusable and struments. are available in various sizes (2 mm, 5 mm, 10 mm, 12 mm, and 15 mm). The obturator tip may be bladed Trocar Insertion Technique or blunt. The blunt-tip trocars may be associated with a lower incidence ofinjury to abdominal wall vessels The primary trocar insertion has already been de- and intraperitoneal structures and are the preferred scribed. All secondary trocars must be inserted under trocars at the author's institute. The larger (10 mm, direct laparoscopic visualization to prevent inadvertent 12 mm, 15 mm) trocars have a valve or reducer sys- visceral injury. The trocar placement site is pressed tem at the proximal end to allow instruments ofvar- with a finger and the indentation made on the abdom- ious sizes to be passed without causing an air leak. inal wall is viewed internally. We prefer to localize the Longer trocars are also available for use in the mor- trocar placement site by puncturing the abdominal bidly obese population. wall with a hypodermic needle attached to a syringe. The trocar is firmly grasped against the palm of the Sites for Trocar Placement hand. The skin incision is made commensurate with the size oftrocar to be inserted. The trocar is inserted Individual sites for trocar placement are described in by a firm constant screwing motion. The trocar detail with each individual operative procedure. How- should be inserted perpendicular to the abdominal ever, there are certain general rules that govern cor- wall. Skewing the trocar through the abdominal wall

Fig. 5. The figure shows a few of the available blunt andbladedtrocars. We prefer to use blunt trocars for all our laparoscopic cases a 12 Laparoscopic Instrumentation 275 results in limited mobility and as the procedure goes Cutting Instruments on the hole tends to enlarge, leading to gas leakage. We prefer to fix all trocars to the skin using an 0-Vi- Monopolar electrosurgical instruments are generally cryl suture. used for cutting tissues during laparoscopic surgery. Straight or curved scissors (Fig. 6) and electrosurgical Grasping Instruments electrodes ofvarious tip configurations (Fig. 7) are available for laparoscopic tissue cutting. Usually a set- A variety oflaparoscopic grasping instruments, dis- ting of 55 W for coagulation and 35 W for cutting is posable and reusable, are currently available. The employed. The shaft of these instruments is insulated grasping instruments may be traumatic or atraumatic, to prevent thermal damage to adjacent structures. locking or nonlocking, have a single or double action jaw, and ofvarious sizes (2±12 mm). The atraumatic Energy Sources for Laparoscopic Surgery graspers generally have serrated tips that are gentle on visceral tissues. The traumatic graspers have toothed Apart from monopolar and bipolar electrocautery, a tips that offer a firm grasp on rigid fascial or similar variety ofdifferent energy sources has been intro- nonvital structures. Typically, the reusable instruments duced for tissue cutting and/or hemostasis during la- are modular wherein different tips can be attached to paroscopic surgery. These include ultrasonic energy, different handles using varying shaft lengths. Ligasure (Valleylab), hydrodissector, and argon beam coagulator.

Fig. 6. The curvedcutting scissors are usedfor sharp dissection

Fig. 7. We use the J-hook monopolar electrode (Karl Storz, Culver City, CA) ex- tensively during laparoscopic surgery. The hook electrode is especially useful for dissection aroundvital structures such as major vessels. The back elbow of the hook is also an efficient blunt dissector 276 M. Aron

Ultrasonic energy has been successfully used for Argon beam coagulation provides excellent superfi- tissue dissection and hemostasis [5]. The commer- cial hemostasis for superficial bleeding surfaces [7]. It cially available ultrasonic generators (harmonic scal- is particularly helpful for controlling mild oozing pel, Ethicon, New Brunswick, NJ; AutoSonix, USSC; from parenchymal bleeding surfaces such as liver, SonoSurg, Olympus) provide a wide array of effecter spleen, kidney, and muscle. Additionally, the argon tips (5 and 10 mm) for laparoscopic surgery. With ul- beam coagulator does not produce any forward scat- trasonic energy, tissue cutting and coagulation is ter. The use ofthe argon beam coagulator during la- achieved at lower temperatures (508±1008C) as com- paroscopic surgery may cause a precipitous rise in in- pared to electrocautery. This reduces the lateral scat- tra-abdominal pressure and so one ofthe trocars ter, charring, and smoke production. Disadvantages of should be continuously vented during its use. the ultrasound dissection include equipment cost and decreased speed ofdissection. Clips and Staplers The Ligasure system is designed for providing hemostatic sealing ofblood vessels up to 7 mm in diam- Surgical clips and staplers form the cornerstone of se- eter [6]. Specific to urologic surgery, the Ligasure has curing medium- and large-caliber vessels during la- been used for securing blood vessels such as the lum- paroscopic surgery. Surgical clips are made ofeither bar, gonadal and adrenal vein in select cases in lieu of titanium (Fig. 8) or plastic and are available in var- surgical clips. The Ligasure technology combines com- ious sizes. Titanium clips can be applied through pression pressure and thermal energy to cause dena- manual loading or self-loading clip applicators. The ti- turation ofthe vessel wall collagen and secure vessel tanium clips do have a tendency to fall off during sub- occlusion. A feedback mechanism regulates the sequent dissection and manipulation and hence multi- amount ofenergy to be delivered and gives an audible ple clips should be used. Importantly, the clips should signal to the surgeon when effective vessel occlusion be evenly spaced and should not cross each other in has been achieved. The Ligasure system is thought to order to be effective. It is also important to leave a produce less charring and tissue sticking compared to sufficient vessel stump after the last clip to ensure conventional bipolar coagulators. safety of the clip ligature. Recently, locking plastic

Fig. 8. Multifire titanium clip applicator a 12 Laparoscopic Instrumentation 277 clips (Hem-o-Lok Clips, Weck Closure Systems, Re- Although various reports have supported the use of search Park, NC) have been introduced to improve the such clips on the main renal vein, we currently reserve efficacy of surgical clips (Fig. 9). These clips are ap- tissue staplers for that purpose. Probably the availabil- plied such that the entire clip encircles the vessel and ity ofa 15-mm Hem-o-Lok clip will enable the reliable once fired, locks into place. These clips are generally clipping ofthe main renal vein. more reliable than titanium clips and are currently Endoscopic stapling devices are generally employed our preferred method of securing medium to large for securing hemostasis for large vascular structures vessels such as the renal artery and venous tributaries. such as the renal vein. Typical endoscopic staplers are

Fig. 9. The Hem-o-Lok plastic locking clip provides reliable and secure closure and is our preferred method of securing the renal artery

Fig. 10. The articulating and reticulating endoscopic stapling devices are used for major vascular pedicles and tissue approximation. Typically the GIA type staplers lay six staggeredrows of staples andcut between rows three andfour 278 M. Aron ofa linear GIA type, lay six staggered rows ofstaples and pushing it through the port with the help ofa and cut between rows three and four (Fig. 10). Cur- knot pusher. It is a useful technique for approximation rently available endoscopic stapling devices can both ar- oftissues under tension. Intracorporeal suturing is ticulate and reticulate, allowing an increased range of used for approximation of tissues without tension. angles for soft tissue and vascular stapling. The stapling The needle can be inserted through a laparoscopic cartridges are available in various lengths (30 mm, port by grasping the suture about 3 cm from the nee- 45 mm, and 60 mm) and various staple heights dle. The trocar sleeve valve should be kept in the open (2 mm, 2.5 mm, and 3 mm). The 2-mm stapling loads position while the suture is being inserted. The size of are typically used for vascular stapling. The 3.5-mm the needle determines the trocar size required; by and loads are used for soft tissue stapling where vascularity large a 10- to 12-mm port is preferred. The suture is to the stapled edges needs to be preserved (e.g., bowel generally cut to a length of7±8 cm for intracorporeal anastomosis). Certain precautions need to be taken with knot tying. The long end ofthe suture is looped two the use ofendoscopic staplers. First, the correct load of or three times around the tip ofthe needle driver and staples must be used as per the type and thickness of to complete the first throw of the surgeon's knot. The tissue to be stapled. Second, care must be taken not to second and the third throws complete a square knot. fire staplers over clips. However, staples can be safely Suturing can be performed in interrupted or running fired over previous staple lines. fashion. A variety of needle drivers with varying tip and handle configurations and locking mechanisms Suturing and Knot Tying are currently available. The novice laparoscopist may consider starting out with a self-righting needle dri- With advances in laparoscopic reconstruction, sutur- ver, although the non-self-righting devices afford the ing and knot tying assumes greater significance. The best results and greatest versatility. Our personal pre- techniques ofintracorporeal and extracorporeal sutur- ference is for the Ethicon needle driver (E705R) ing along with the application ofendoloops are neces- (Fig. 11). sary skills for the advanced laparoscopic surgeon [8]. A variety ofspecialized suturing devices have been The endoloop consists ofa preformed loop ofsu- introduced to facilitate laparoscopic intracorporeal suture with a slipknot at the end ofa plastic knot turing and knot tying. These include the Endostitch pusher. This device may be used for ligating tubular (USSC,) and SewRight (LSI Solutions, Victor, NY). organs such as the appendix. Although these devices may aid the beginner laparos- Extracorporeal knotting involves formation of the copist, in our opinion, they lack the finesse of free- knot by a long suture (about 1 m) outside the cavity hand suturing. Additionally, the laparoscopic surgeon

Fig. 11. We prefer the straight tip needle driver for intracorporeal laparoscopic suturing (Ethicon, model E705R) a 12 Laparoscopic Instrumentation 279 is limited with the type ofsuture and needle config- matrix thrombin tissue sealant (Floseal, Baxter Inc., urations available. Deerfield, IL) is a two-component tissue sealant, con- sisting ofa gelatin matrix granular component and a Glues, Bioadhesives and Hemostatic Agents thrombin component. Preliminary data reveals that Floseal has been shown to provide immediate and Closure oflaparoscopic port-site incisions with skin durable hemostasis in laparoscopic partial nephrect- adhesives such as Octylcyanoacrylate (OCA) has been omy. In a select patient population, use ofthis agent found to be as effective as subcuticular suturing in may reduce the hemorrhagic and overall complication terms ofadverse wound outcomes with the advantage rate after laparoscopic partial nephrectomy [10]. Tis- ofrequiring less operative time [9]. Other adhesives seel (Baxter Inc.) is a tissue sealant and hemostatic such as N-butyl-2-cyanoacrylate (NBCA) have also agent. Initial data with Tisseel as regards hemostasis been used with similar effect, but OCA is the only one and urine leak after laparoscopic partial nephrectomy that has FDA approval. OCA carries the disadvantage are encouraging [11]. ofhaving a learning curve forproper use ofthe prod- Suture repair ofthe renal parenchymal defectover uct. Moreover, OCA has to be applied to dry, well-ap- surgical bolsters [12] and the combined use offibrin proximated incisions and the product must not be al- glue and Gelfoam are also effective means to obtain lowed to seep inside as a vigorous foreign body reac- hemostasis during laparoscopic surgery [13]. tion resembling an infection often ensues. A variety ofhemostatic agents and tissue sealants Aspiration and Irrigation Instruments have been recently used in laparoscopic surgery. These agents have been specifically utilized in laparoscopic A variety ofsuction-irrigation systems are currently partial nephrectomy, where hemostasis ofthe renal available (Fig. 12). The aspirator, which is connected remnant and urine leak are specific concerns. Gelatin to a suction system, consists ofa 5- or 10-mm metal

Fig. 12. The Stryker suction andirrigation system has a reu- cannula is invaluable for suction, irrigation andblunt dissec- sable cannula anddisposabletubing that incorporates a tion andis the author's instrument of choice for this pur- battery driven pump. The 5-mm blunt-tip sump suction pose 280 M. Aron tube, with suction controlled by either a one-way stop Insufflant System cock or a spring-controlled trumpet valve. The irrigation channel is also operated by the same mechanism. The insufflant system (i.e., insufflator, tubing, and in- The irrigation may be pressurized to adequately clear sufflant gas) is essential for establishing a pneumoper- blood clots for optimal visualization. Usually saline or itoneum, or pneumoretroperitoneum, as the case may lactated Ringer solution is used as the irrigation fluid. be. This is brought into use once the closed (i.e., Ver- Heparin (5000 U/l) may be added to prevent clots ess needle) or open (i.e., Hasson cannula) access to from forming in the surgical field. Furthermore, a the desired cavity is established. broad-spectrum antibiotic may be added to the irri- Most commonly, CO2 is used as the insufflant be- gant in cases where infection is a concern. cause it does not support combustion and is highly soluble in blood [19]. However, in patients with

chronic respiratory disease, CO2 may accumulate in the blood stream to dangerous levels. Accordingly, in Instrumentation for Port Site Closure these patients, helium may be substituted once the ini- The simplest method is retracting the skin with re- tial pneumoperitoneum has been established with CO2 tractors, grasping the fascia with Kocher's clamps, and [20]. However, helium is significantly less soluble in suturing it with sutures. However, external suture of blood than CO2. Other gases that were once used for 1-cm port site incisions may be extremely difficult, insufflation (room air, oxygen, nitrous oxide) are no especially in the obese population. longer routinely used owing to their potential side ef- Several specialized devices for secure port site clo- fects (e.g., air embolus, intra-abdominal explosion, po- sure have been introduced [15±18]. The Carter-Tho- tential to support combustion). Noble gases such as mason needlepoint suture passer (Inlet Medical, Eden xenon, argon, and krypton are inert and nonflam- Prairie, MN) consists ofa 10-mm metal cone that has mable but are not routinely used for insufflation ow- two cylindrical passages located diagonally opposite ing to their high cost and poor solubility in blood. each other. The Carter-Thomason needle grasper is Initially, insufflator pressure is set at 15 mmHg used to insert one end ofthe suture loop through one with a rate ofgas flow of1 l/min. Once safeentry into ofthe cylinders within the cone, thereby traversing the peritoneal cavity has been achieved, the flow can muscle, fascia, and peritoneal layers. The end of the be increased. The 14-gauge Veress needle cannot deli- suture within the peritoneal cavity is grasped with a ver flow rates greater than 2 l/min. 5-mm grasper via one ofthe other ports by the assis- The insufflated CO2 is cold (218C) and is unhumi- tant. The Carter-Thomason needle grasper is reintro- dified [21]. This results in minimal cooling of the pa- duced through the other cylinder ofthe metal cone. tient and likely contributes to problems offogging of The intraperitoneal end ofthe suture is fedto the nee- the endoscope during the procedure. Accessory de- dlepoint grasper and pulled out ofthe abdomen. The vices for insufflators that warm and humidify laparo- metal cone is slid off both ends of the suture. Subse- scopic gas to physiologic conditions are available. quently, the suture is tied after desufflating the abdo- However, the benefit of humidification is largely un- men to provide adequate fascial closure. proven. The eXit disposable puncture closure device (Pro- gressive Medical, St. Louis, MO) is another such de- Visualization System vice that is inserted through a laparoscopic port larger than 10 mm. Herein, the special right-angle needles To create a laparoscopic image, four components are are passed in a retrograde manner from the inside of required: laparoscope, light source with cable, camera, the abdomen to the outside. Using animal models, the and monitor. Laparoscopes that are most commonly eXit disposable puncture closure and the Carter-Tho- used have 08 or 308 lenses (range, 08±708) and a size mason needlepoint suture passer were found to have of10 mm (range, 2.7±12 mm). Image transmission some advantages over other devices [15]. The Carter- uses an objective lens, a rod-lens system with or with- Thomason needlepoint device not only is helpful for out an eyepiece, and a fiberoptic cable. The advantage wound closure but also can be used to obtain hemos- ofthe larger laparoscopes is that they are able to pro- tasis in the event ofinjury to an abdominal wall vessel vide a wider field of view, better optical resolution, during trocar insertion. and a brighter image. From the eyepiece, the optical a 12 Laparoscopic Instrumentation 281 image is magnified and transferred to the camera and the 308 lens thus provides the surgeon with a more onto the monitor. Light is transmitted from the light complete view ofthe surgical fieldthan does a 0 8 lens. source through the fiberoptic cable onto the light post A vexing problem with the laparoscope is fogging ofthe laparoscope. A special variant is the offset ofthe lens. To minimize fogging ofthe laparoscope working laparoscope, which includes a working chan- after insertion into the warm intraperitoneal cavity, it nel for passage of basic laparoscopic instrumentation; is advisable to initially warm the laparoscope in a use ofthis type oflaparoscope enables the surgeon to container holding warm saline before it is passed into work in direct line with the image and may allow a re- the abdomen. In addition, wiping the tip with a com- duction in the number oftrocars needed to accom- mercial defogging fluid or with povidone-iodine solu- plish a particular procedure. However, the working tion is also recommended. Should moisture buildup channel occupies space that would otherwise be used occur between the eyepiece and camera, both compo- for the optical system; hence, the resulting image is nents must be disconnected and carefully cleansed usually oflesser quality compared with that oflaparo- with a dry gauze pad. scopes without this feature. Video monitors are available in 13- or 19-in. sizes. The camera system consists ofa camera and a vi- A larger monitor does not produce a better picture; deo monitor. Earlier cameras could not be sterilized; indeed, given the same number oflines on both moni- hence, a sterile plastic camera wrap had to be passed tors, a higher-resolution image is obtained with the over the camera and the eyepiece ofthe laparoscope. smaller screen. To obtain a better image, more lines of The camera wrap was then affixed to the shaft of the resolution are needed. High-resolution monitors with laparoscope with wire ties. Most currently available 1,125 lines ofresolution must be matched with a cam- cameras can be chemically sterilized, thereby making era system ofsimilar capability. them more user-friendly and minimizing a possible Light sources use high-intensity halogen, mercury, source ofcontamination. The camera is attached di- or xenon vapor bulbs with an output of250±300 W. rectly to the end ofthe laparoscope and transfers the Xenon, 300-W lamps are currently preferred. In addi- view ofthe surgical fieldthrough a cable to the cam- tion to manual control ofbrightness, some units have era box unit. After reconstruction of the optical infor- automatic adjustment capabilities to prevent too much mation, the image is displayed on one or two video illumination, which may result in a washed out image. monitors. Any breakage of fibers in the fiberoptic cable, which A wide variety ofcameras are currently available: may occur during sterilization and/or improper han- single-chip, single-chip/digitized, three-chip, three- dling, results in decreased light transfer from the light chip/digitized, interchangeable fixed-focus lenses, source to the laparoscope, and hence to the operating zoom lenses, beam splitter, and direct coupler. Direct field. couplers are superior to beam splitters, in which light and image are shared between monitor and eyepiece and in which the surgeon may view the area ofinter- Operating Room Setup est directly through the laparoscope. Three-chip cameras are superior to single-chip cameras in that they The operating room has to provide enough space to provide a higher-quality image with superior color re- accommodate all necessary personnel and the techno- solution. logic equipment required by both the laparoscopist To obtain a true upright image ofthe surgical field and the anesthesiologist. Positioning ofequipment, on the monitor, the camera's orientation mark must surgeon, assistants, nurses, anesthesiologist, and other be placed at the 12-o'clock position. With 08 laparo- support staff should be clearly defined and established scopes, the camera is locked to the eyepiece in the for each standard laparoscopic case. All equipment true position. In contrast, with the 308 laparoscope, must be fully functional and in operating condition the camera is loosely attached to the eyepiece ofthe before any laparoscopic procedure is started. A sepa- laparoscope so the laparoscope can be rotated. Ac- rate tray with open laparotomy instruments must be cordingly, the assistant must hold the camera in the ready for immediate use in the event of complications true upright position with one hand while rotating the or problems necessitating open incisional surgery. laparoscope through a 3608 arc to peer over and around vascular and other intra-abdominal structures; 282 M. Aron

Fig. 13. A Patient positioning for upper tract laparoscopy. The patient is in a full or modified flank position. The bony prominences are adequately padded and extremities are in a neutral position. B Patient positioning for pelvic laparoscopy. The patient is in a modified low- lithotomy position with a Trendelenburg tilt. The arms are tuckedto the sideand adequately padded

Patient Positioning and Draping any ofthe positioning straps and the hip or shoulder should be padded. In the lateral position, the bottom Positioning ofthe patient depends primarily on the la- leg is flexed approximately 458 while the upper leg is paroscopic procedure to be performed (Fig. 13A,B). kept straight; a pillow is placed between the legs as a Most laparoscopic procedures start with the patient in cushion and also to elevate the upper leg so that it lies a supine position with the arms secured at the sides level with the flank, thereby obviating any undue stretch ofthe body. In the Trendelenburg or lateral position, on the sciatic nerve. Application ofactive warming sys- tape and security belts applied across the chest and tems may prevent hypothermia should a lengthy laparo- thighs provide safe and stable positioning of the patient. scopic procedure be anticipated. In the lateral position, all bony prominences must be The full extent of the abdominal wall should be carefully padded; likewise, the point of contact between prepared and draped from nipples to pubis. In some a 12 Laparoscopic Instrumentation 283 procedures, it is advantageous to extend the prepara- dominal contents during insertion ofthe Veress needle tion to the knees and to drape the external genitalia and the initial trocar. Pneumatic compression stock- into the surgical field. For example, gently pulling on ings are applied as antiembolic prophylaxis. the testicle may help identify the intrapelvic location ofthe vas deferens and spermatic vessels, insertion of Placement of Operative Team the surgeon's index finger into the vagina certainly fa- and Equipment cilitates laparoscopic bladder neck suspension, and free access to the urethral meatus enables the perfor- Ifonly one monitor is used (as in intrapelvic proce- mance ofauxiliary procedures such as flexible cysto- dures), it is typically placed at the foot of the table. If scopy or manipulation ofureteral catheters during a two monitors are used, they are positioned on either laparoscopic nephroureterectomy or for stent place- side ofthe table opposite the primary surgeon and the ment at the end ofa laparoscopic pyeloplasty. assisting surgeon, respectively, to allow an unob- Before major laparoscopic procedures, placement of structed view (Fig. 14A,B). a nasogastric tube and a Foley catheter is usually per- The cart with the monitor for the primary surgeon formed to decompress stomach and bladder, respec- should also contain the insufflator, placed at the sur- tively, thereby decreasing the chance ofinjury ofab- geon's eye level, to allow continuous monitoring ofthe

AB Fig. 14 A, B. Operating room layouts for (A) upper tract and( B) pelvic laparoscopic surgery. The illustration highlights the relative positions of the surgeon, assistants, scrub nurse andequipment duringlaparoscopic renal andadrenalsurgery 284 M. Aron

CO2 pressure. The light source, camera controls, and 5. An extra tank ofCO 2 in the room any recording device are also on this cart. 6. A Veress needle, checked to ensure that its tip re- The surgeon usually stands opposite the area of tracts properly and that, when it is connected to surgical interest and the assistant stands on the ipsi- the insufflator tubing, the pressure recorded with lateral side ofthe table. The second assistant stands 2-l/min CO2 flow through the needle is less than on the contralateral side ofthe table. With two moni- 2 mmHg tors in use, the instrument table and the scrub nurse are on the side ofthe surgeon toward the end ofthe table. Incoming lines from insufflator, suction/irriga- Conclusion tion, and electrosurgical devices enter from the contralateral side ofthe table. Optional technology (e.g., In recent years, urologic laparoscopy has breached harmonic scalpel, argon beam coagulator) must be ar- new frontiers and has evolved into a specialized disci- ranged in an orderly fashion using either preexisting pline in itself. Procedures, which until recently were or improvised pockets ofthe surgical drape. Again, considered beyond the scope oflaparoscopic surgery, these lines ideally should enter the field from the con- are now being increasingly performed safely and ef- tralateral side ofthe table or from the ipsilateral head fectively by laparoscopic surgeons all over the world. ofthe table. Robotic devices for electronically con- The foundation of successful laparoscopic surgery lies trolled or voice-controlled camera manipulation in the strict adherence to age-old, established surgical should be brought into the operative area from the principles, proper training ofpersonnel in laparo- contralateral side ofthe table to prevent any limitation scopic skills, and good equipment. In this chapter we ofthe surgeon's maneuverability during the procedure. have covered the practical fundamentals of laparo- Additional technology (e.g., high-speed electrical tis- scopic urology, which go a long way in ensuring a sue morcellator, laparoscopic ultrasound probe) may successful outcome for the patient and surgeon alike. be moved to the operating table depending on the surgeon's needs as well as on the availability ofspace [22]. To provide more comfortable positioning of the References surgeon's arms, a 15-cm foot-stool can be used, be- cause most operating tables cannot be lowered suffi- 1. Florio G, Silvestro C, Polito DS (2003) Periumbilical ciently to allow the surgeon to hold the laparoscopic Veress needle pneumoperitoneum: technique and results instruments with his or her arm comfortably ex- in 2126 cases. Chir Ital 55:51±54 tended. Using this type ofliftis especially helpfuldur- 2. Barwijuk AJ, Jakubiak T, Dziag R (2004) Use ofthe Has- son technique for creating pneumoperitoneum in la- ing laparoscopic suturing. paroscopic surgery. Ginekol Pol 75:35±38 A checklist ensuring that all essential equipment is 3. Matin SF, Gill IS (2002) Laparoscopic radical nephrect- present and operational should be completed just be- omy: retroperitoneal versus transperitoneal approach. fore initiating the pneumoperitoneum. Specifically, Curr Urol Rep 3:164±171 this list should include: 4. Gill IS, Rassweiler JJ (1999) Retroperitoneoscopic renal 1. Light cable on the table, connected to the light surgery: our approach. Urology 54:734±738 source and operational 5. Todorov G, Baev S, Velev G (1997) Dissection with an ultrasonic dissector during laparoscopic cholecystect- 2. Laparoscope connected to the light cable and to the omy. Khirurgiia (Sofiia) 50:43±44 camera, with an image that is white balanced and 6. Romano F, Caprotti R, Franciosi C, de Fina S, Colombo focused on a gauze sponge G, Sartori P, Uggeri F (2003) The use ofLigaSure during 3. Operational suction and irrigation functions of the pediatric laparoscopic splenectomy: a preliminary re- irrigator/aspirator port. Pediatr Surg Int 19:721±724 4. Insufflator tubing connected to the insufflator, 7. Kwon AH, Matsui Y, Inui H, Imamura A, Kamiyama Y which is turned on to allow the surgeon to see that (2003) Laparoscopic treatment using an argon beam coagulator for nonparasitic liver cysts. Am J Surg there is proper flow of CO , through the tubing; 2 185:273±277 kinking ofthe tubing should result in an immedi- 8. Desai MM, Gill IS, Kaouk JH, Matin SF, Novick AC ate increase in the pressure recorded by the insuf- (2003) Laparoscopic partial nephrectomy with suture flator, with concomitant cessation of CO2 flow repair ofthe pelvicaliceal system. Urology 61:99±104 a 12 Laparoscopic Instrumentation 285

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