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 nee- dle is directed towards the pelvis in order to avoid in- jury 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 in- sufflated 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 inci- sion for the initial port site so as to reduce the grip- ping ofthe skin on the trocar. Additional trocars are subsequently inserted under laparoscopic visualiza- tion, thereby minimizing the risk ofinadvertent vis- ceral or vascular injury. The closed approach for ob- taining transperitoneal access has been criticized as being blind and having greater risk for inadvertent in- jury 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 retroperito- neum. 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 retro- peritoneal 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 ne- phrectomy), and should be approximately at a 458 an- Laparoscopic Trocars gle to the area