Instruments used in Laparoscopic surgery.pptx

Instruments used in Lap surgery

1. Disclosure I have no actual or potential conflict of interest in relation to this program/presentation Instrument Handling in Laparoscopy Surgery Prof. Dr. Mohammed Shadrul Alam MBBS, MS, FCPS, FRCS, FACS Pediatric Urologist & Health Economist MuMCH

2. What is laparoscopy and its applications History Instruments ( details) Indications and contraindications Physiological changes Port of laparoscopy Complications during operation Commonly practiced laparoscopic surgeries Contents

3. Definition It is a minimally access procedure allowing endoscopic access to peritoneal cavity after insufflation of gas to create space between the anterior abd . Wall & viscera for safe manipulation of instruments & organs.

4. What is laparoscopic surgery? Operation performed in pelvis or abdomen through small incisions Done for diagnostic purpose or to perform a surgery Small camera called laparoscope is used Benefits- patients experience less pain, smaller chance of hemorrhaging, and shorter recovery time

5. Tools for Standard Laparoscopic Surgery 2 types of laparoscopes: 1) Telescopic rod lens system -attached to a video camera 2) Digital laparoscope -fiber optic cable system is connected to a light source so operative area can be illuminated -then inserted through tiny tube (cannula) to see the operation -abdomen is then insufflated with carbon dioxide (not harmful to body) to raise abdominal wall above organs

6. HISTORY George Kellingused cystoscope to observe abd organs of dogs— CYSTOSCOPY 1910 – Swedish physician Hans Christian Jacobaeus used this procedure in man and coined the term – LAPAROSCOPY 1987 – Mourett in France successfully removed a diseased gall bladder laparoscopically

7. Introduction Laparoscope = thin telescope with light source Minimally invasive surgical technique Operations in abdomen or pelvic cavity Laparoscope inserted 5-10mm canula Side port 5-10mm for grasper Abdomen insufflated: CO 2 or N gas Details of Laparoscopy:

8. Introduction (cont.) Why Laparoscopy? Minimize blood loss Minimize post-operative pain Expedite recovery time Less risk of complications A much smaller scar

9. Endoscopic vs. Laparoscopic Surgery Endoscopy : An illuminated usually fiber-optic flexible or rigid tubular instrument for visualizing the interior of a hollow organ or part (as the bladder or esophagus) for diagnostic or therapeutic purposes that typically has one or more channels to enable passage of instruments (as forceps or scissors). Examples: bronchoscopy, cystoscopy . Laparoscopy: 1: visual examination of the inside of the abdomen by means of a laparoscope—called also peritoneoscopy 2: an operation (as tubal ligation or gallbladder removal) involving laparoscopy . Examples: laparoscopic appendectomy, LAVH.

10. Smaller incisions Less likely to suffer wound-related complications. Less post-operative pain Decreased hospital stay Some laparoscopic procedures are performed on an outpatient basis. Accelerated recovery and improved outcome Advantages of Laparoscopic Procedures

11. Background Problem at hand: Clips restrain tissue from surgical procedure High pressure, tissue closest to joint Phenomenon : Tissue expelled, trauma caused

12. Design Objective Grasping instrument designed for internal use Minimize moving parts and safety hazards Equalize pressure across length of clip Device must be <5mm diameter Specifications:

13. INSTRUMENTS USED Zero degree laparoscope Cold light source (Halogen and Xenon lamp) Camera ( 3chip camera commonly used with high resolution Video monitor to display images CO2 insuffulator Long fine dissectors Hooks and spatulas with cautery for dissections Clip applicators Needle holders Veress needle Trocars of different sizes – 10mm, 5mm Suction irrigation apparatus Reducers to negotiate smaller instruments through larger ports

14. Telescope There are three important structural differences in telescope available 1. 6 to 18 rod lens system telescopes are available 2. 0 to 120 degree telescopes are available 3. 1.5 mm to 15 mm of telescopes are available

15. Instruments Used in Laparoscopic Procedures  Trocars and cannula  Insufflators & Veress needle  Light source & light cord  General lap. instrumentation  Laparoscope

16. Trocar & Cannula Trocars and cannula are instruments used to access the surgical site through small incision or puncture holes (an access port). They are made in both reusable and disposable varieties. Stainless Reusable Trocar System Yello -Port Reusable Trocar System

17. Trocar The trocar has a blade with a shaft and body. The body includes a pointed tip which makes the initial incision in the abdominal wall of the patient. (Trocar diameters range from 2mm-30 mm) Most common trocer is 5mm & 10mm Technique Head end of the table is lowered to have easier insertion of needle scope Pressure bandages are applied to both legs to improve the venous return Ryle’s tube and foley’s catheter are essential before insertion of the trocars Pneumoperitoneum is created using veress needle through umbilical incision

18. Insufflator The insufflator is a device that enables visualization of the internal surgical area by creation of a pneumoperitoneum . This is accomplished through pumping carbon dioxide gas into the abdomen under pressure through the Veress needle.

19. Laparoscopic Instrument Types There are dozens of different types of laparoscopic instruments. We will examine a few of the main families of laparoscopic instruments

20. Laparoscopic Instrument Types Traumatic Graspers Atraumatic Graspers Teeth

21. Needle Holders Retractors

22. Light Source Degree of brightness Powerswitch Brightness adjustment Fibre-opticcable Department of Surgical Research and Techniques 5thPractice Check the light cable before use!

23. Telescope ( bajonet ) joint Programing /White balance Focus ring Zoom ring Cabeltothecontroller Department of Surgical Research and Techniques

24. Patient Safety Begins With Decontamination Healthcare staff who are responsible for processing laparoscopes and associated items can have a major impact on the risk for surgical site infections (SSI) during laparoscopic procedures. Over 90% of infection outbreaks related to laparoscopic instruments can be prevented if processing of instruments and equipment is properly conducted.

25. AORN recommends that individuals handling laparoscopic instruments should be competent in their care and handling. Instruments with lumens are among the most difficult to decontaminate effectively. Decontamination: Care & Handling Always wear personal protective equipment and follow standard precautions.

26. Assembly : Care & Handling It is important to remember that surgical instruments are complex and fragile. Personnel who are responsible for instrument care should: •Be cautious when handling instruments. •Use all instruments, tools, and equipment for their intended purpose only. •Follow processing protocols carefully.

27. Inspection : Care & Handling  Laparoscopic instruments should be inspected after use, ALL instruments in set!  Evaluate equipment’s integrity, function, and cleanliness .  All insulated laparoscopic instruments should be tested with a current tester every time the set is assembled!  Damaged instruments should removed from service.

28. Equipment failures can compromise patient safety in several ways. Prior to use, all laparoscopic instruments must be tested .  Compromised insulation can cause internal patient burns. A video example is shown on the next slide.  Surgeon and scrub tech can be burned by broken insulation in instruments.  Cracked insulation can allow bioburden to become trapped and instrument sterility is compromised. Inspection: Insulation Testing With proper laparoscopic instrument testing each time the instrument is reprocessed, these burns can be avoided.

29. Spaulding Classification System

30. Care & Cleaning In order to avoid drying of operation residues and spreading of germs in the endoscopy areas, the instruments must be placed in a combined disinfecting and cleaning solution immediately after use. In connection with this: Store optical and mechanical components separately. Dismantle instruments. Take off rubber and sealing caps. Clean thoroughly since blood, pus, protein residues etc. can call subsequent disinfection or sterilization into question. Clean existing inner areas, such as guide channels etc., with the relevant cleaning brush and swab. Rinse open valves and narrow channels with a cleaning gun. Carry out rinsing and brushing of the channels under the surface of water, to avoid spraying of germs in the environment. Rinse all components first with cold and then with warm water. Lay the used instruments carefully in the boxes. The detergent solution must be appropriate for the disinfectant. Lay the instruments in a combined cleaning and disinfecting solution. Subsequently rinse with distilled water and then dry inside and out with a cloth, swab or dry air.

31. Inspection & Functionality Inspect instruments for functionality and for any damage that has occurred after each cleaning. Replace brittle and cracked sealing caps. Oil all moving components sparingly after cleaning with endoscope oil. Wipe off excess oil with a disposable towel. Sparingly grease rotating valves, valve pistons from trocar sleeves etc. after cleaning (before steam sterilization) with endoscope grease. Inspect the insulation of the cable and connections for cuts, holes, cracks, blowing, wear, etc. Do not use any damaged instruments. Send damaged instruments to the factory for repair.

32. What gas is commonly used to inflate the abdominal cavity for a laparoscopic procedure ? Oxygen Carbon Dioxide Carbon Monoxide Nitrous Oxide What is the medical term for making internal organs easier to visualize by inserting gas into the abdominal cavity? Pneumoperitoneum Pneumothorax Pneumonisis Indigestion

33. What instruments are used to access the surgical site through small puncture holes? Trocanter & Cannula Trocar & Candlestick Trocar & Cannula Trocanter & Calendula What is an advantage of minimally invasive surgery? Smaller Incision Decreased Hospital Stay Less Pain All of the above

34. What is part of the laparoscopic instrument inspection process contributes the most to patient safety? Assuring it’s lubricated Checking for faulty insulation Handle feels comfortable Tip protectors are secured LAVH is an abbreviation for a surgical procedure. What does the abbreviation stand for? Look Around Very Hard Lap Assisted Vaginal Hysterectomy Lap Assisted Vaginal Hysteroscopy Laparotomy And Vaginal Hysterectomy

35. CONTRAINDICATIONS 1. Absolute - none 2. Relative i ) severe COAD ii) recent MI iii) ventriculoperitoneal shunts iv) Increased ICT v) extensive organomegaly vi ) CHF

36. Complications Insertion Related : Major vascular injury GI Injury Bladder injury CO2 embolism Abdominal wall haemorrhage Post Insertional : GI perforations Laceration & bleeding from solid organs Abdominal wall hernia Pneumoperitoneal Related: CO2 embolism Hypercarbia Respiratory acidosis Subcutaneous emphysema Renal failure Venous thrombosis Pneumothorax

37. Ergonomics of Laparoscopy Increased Time/Fatigue Length of instruments - Increased Tremor - Only about 4 Degrees of Freedom compared to human hands that provide 36 DOF and mechanical redundancy Spatial disorientation/ instrument movement - Fulcrum Effect Greater force required to grip instruments Only one size of instruments often available

38. Ergonomics of Laparoscopy Increased Time/Fatigue * Reduced ability to sense tissue characteristics Surgical Fatigue Syndrome - A four hour performance “ wall ” that is manifested by mental exhaustion, irritability, impaired surgical judgment, and reduced manual dexterity Visual fatigue - long term effect is unknown Possibly significant cardiovascular stress *D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related surgeon morbidity syndromes, Surgical Endoscopy , v.20(1), p. 1-13

39. Ergonomics of Laparoscopy Posture * Overhead or side placement of monitor - Ideal placement is to the front, near the hands There is an increase in the amount of equipment, which leads to a need to maneuver around them Stiff upright with little movement - Less opportunity to shift weight Requires raised arms placed in awkward positions for extended periods of time *D. A. G. Reyes, B. Tang, A. Cuschieri, 2006, Minimal access surgery (MAS)-related surgeon morbidity syndromes, Surgical Endoscopy , v.20(1), p. 1-13 Berguer R., 1999, Surgery and ergonomics, Archives of Surgery , v.134(9), p. 1011-1016

40. Ergonomics Of NOTES No tactile response Visual fatigue Constant holding of the endoscope induces fatigue Endoscopy can lead to musculoskeletal pain in fingers, wrists and shoulders * Young Hye Byun, Jun Haeng Lee, Moon Kyung Park, 2008, Procedure-related musculoskeletal symptoms in gastrointestinal endoscopists in Korea, World J Gastroenterol, v.14(27)

41. Minimally Invasive Surgery: Robot Assisted

42. Why  Robotic  Surgery ? a 400X magnified 3D high-definition vision with adequate precision and control special wristed instruments that bend and rotate far greater than the human wrist Less blood loss Shorter total operating time Less need for narcotic pain medicine Shorter hospital stay Faster return to normal activities

43. Nevertheless, disadvantages to robotic-assisted laparoscopic surgeries are no tactile feedback, increased setup time, and cost

44. The Ever Changing Future A New Endoscopic Microcapsule Robot using Beetle Inspired Microfibrillar Adhesives * * Proceedings of the 2005 IEEE/ASME International Conference on Advanced Intelligent Mechatronics Monterey, California, USA, 24-28 July, 2005

45. The Ever Changing Future Nanobots Operated by Clinician Engineers or Surgeons?

46. T hank You