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� 1
BasicsonLaparoscopicInstrumentationandApparatuses
LiselotteMettler
UniversityofKiel
Intheearlyyearsofgynaecologicalendoscopytherewereonly5-10industrial
companiesworldwideproducinginstrumentsandequipmentforlaparoscopic
surgery.Today,thereareover200companiesofferingequipmentfor
laparoscopicsurgery.Here,wereportontheproductsofsomereliableindustrial
partnerswhoseproductsweuseorareknowntouswithoutanyclaimtothe
completenessofthecontent.
Allessentialequipmentforgynaecologicalandgenerallaparoscopicsurgeryis
assembledonanequipmenttrolley(Fig.1).
� Figure1: SMARTCART:Equipmentcartforgynaecologicendoscopicsurgery(laparoscopyand
hysteroscopy)withelectrosurgicalunit,CO2pneuautomaticwithheatedgas,lightsourceand
HDTVmonitor(KarlStorz3DSystem)aswellascontrolunitforhysteroscopicsurgery(Karl
Storz)
� 2
ForefVicientendoscopicworkitisnecessarytoensurethatthesurgeoncan
checktheequipmentandsettingsataglance.Newer,improved,user-friendly
developmentsarethetouchsensitivepanelsthataredirectlyoperatedbythe
surgeonandthevoice-controlledunits.Industryiscontinuallydevelopingnew
technologiestomeetsurgicalrequirements.
TheVirstvoice-controlledcamera-holdingarm,AESOP(AutomatedEndoscopic
SystemforOptimalPositioning)[1],haslongbeenreplacedbysmallervoice-
controlledcompactmotorizedendoscopeholders,suchastheViKY®EPEndo
ControlSystem(EndocontrolInc,Dover,USA).Morecomplexrobotsystemshave
gainedgroundmainlyinoncologicsurgery. ThedaVincisystemofIntuitiveSurgical,Inc.(Sunnyvale,CA,USA)has
undergonearemarkabledevelopmentduringthelasttenyearsenablinga
surgeonsittingataconsole,afewfeetfromthepatient,toperformdelicateand
complexoperationsthroughafewtinyincisionswithincreasedvision,precision,
dexterityandcontrol.ThedaVinciSurgicalSystemconsistsofseveralkeycomponents,including:an
ergonomicallydesignedconsolewherethesurgeonsitswhileoperating,a
patient-sidecartwherethepatientliesduringsurgery,fourinteractiverobotic
arms,ahigh-deVinition3Dvisionsystem,andproprietaryEndoWrist®
instruments.Therobotdoesnotreplacethesurgeonbutrobotic-assisted
surgeryisseenasapossiblemethodofovercomingthetechnicalchallengesof
conventionallaparoscopy.AnothertelesurgicalsystemistheTelelapALF-X
(SofarS.p.A.,Milan,Italy).
Routineendoscopytrolleyswiththeunitsofthelatetwentiethcenturyhavebeen
replacedbypanoramicoperatingroom(OR)endoscopicsettings,suchasthe
OR1™NEO(KarlStorzGmbH&Co.KG,Tuttlingen,Germany)(Fig.2).
� 3
� Figure2: OR1™NEO(KarlStorz)withpanoramicviewingpossibilities,integratedcommandingfunctions
foralloperativeproceduresanddocumentation
ThenewlydesignedOR1™NEOallowsallsurgicalandtechnicalfunctionstobe
controlledandmonitoredfromtheuserinterfacewithinthesterilearea.The
trolleyincludesallnecessaryapparatusestobeselectedandcontrolledbythe
surgeon:endoscopiccamera,lightsources,insufVlators,suctionandirrigation
pumps,electricalenergysystems,AIDAcompactNEOdocumentationsystems
andOR1™AVsystemNEOsolutions.AIDAcompactNEOusesthehighestdigital
resolutionspeciViedforHDof1920x1080pixels,equalto5timestheimage
informationavailablefromtoday’sPALstandard.Anew,nearly3Dpanoramic
viewmonitorcombinesthedepthoffocuswithenhancedcolourbrilliancefor
improvedergonomicviewing.Thesesystemsarecompatiblewiththirdparty
devices,suchasORlights,energyunits(e.g.Erbotom),lasersandmodern
thermofusionsystems.
OtherpanoramicORsystemsaretheENDOALPHAorVisera-EliteofOlympus
withtheEndoEye,afascinatingcamerasystemwiththecameraatthetipofthe
scopewithoutheatproductionandtheSTRIKERunitwiththedigital
documentationsystemSDCUltra.
� 4
TheideaofwarmingandhumidifyingtheCO2gastoavoiddamagetothe
peritoneumhasbeenpropagatedbyDouglasOttandPhilippeKoninckx.The
HumiGard™ofFisher&PaykelHealthcare(Auckland,NewZealand)provides
heated,humidiViedandVilteredgastoapatientatapredeterminedtemperature.
TodayeveryCO2pneuautomaticprovidesupto37°CheatedCO2gaswhichis
controlledbyapressureregulatorandwithinthemachinebyapplyingthe
Quadro-test.IntheQuadro-testthevolumeofgasVlowingthroughtheVeress
needleduringinsufVlation,intra-abdominalpressure,totalvolumeandpreset
Villingpressurearemeasured.ColdlightisprovidedbyXenonlamps.Thevideo
camerasystemsareequippedwiththree-chipcameraorHD-camerasandcanbe
usedforlaparoscopyaswellashysteroscopy.
High-resolutionvideomonitorsguaranteeoptimalpicturequality.The
technologicaldevelopmentallowstheuseoflargermonitorsinHDqualitythat
facilitatearelaxedworkingatmosphereforthesurgeon.
Arealistic,truetolifethree-dimensionalpictureispossibleduetovarious
technologicalelementssuchasdigitalsimulation,asecondcamerasystemorthe
useofshutterlens.Digitaldevicesforthevideocameracontrolthepicture
qualityandfacilitateautomaticwhitebalancing.TheKarlStorzcompanyalready
offerstheTRICAM3Dimagingsystemthatallowsthesurgeontoviewcrisp,clear
imagesthroughapairoflightweightpolarizingglasses.TheENDOCAMELEON®
laparoscopeprovidesaviewinganglethatcanbeadjustedcontinuously
between0°and120°(Fig.3).
� Figure3: ENDOCAMELEON®laparoscope(KarlStorz)
� 5
Varioustechniquespermitsafecuttingaswellascoagulation.Theearlier
thermocoagulatorentirelyavoidedtheVluxofcurrentthroughthetargettissue
andmadehaemostasissafebyheatingitupto100-1200C[2].Today,modern
electronichighfrequencysystemswithmono-andbipolarcurrentsarewidely
used.Theequipmentforothertechniques,suchastheargonbeamer,laserand
ultrasoniccuttingequipment,isputonanancillarytrolley.EfVicientsuction
irrigationapparatusesremovebodyVluidsaswellasabdominallavagewitha
warmirrigationsolutionandarestandardequipmentforlaparoscopyaswellas
laparotomy.
TheuniversalperturbationapparatusisusedfortheCO2insufVlationofthe
fallopiantubesingynaecology.Acervicaladaptercanbesimultaneouslyinserted
forintraoperativemanipulationaswellasforhydroandchromopertubation.The
hysteroVlaterfacilitatesgasorVluidhysteroscopywithcontrolofbothinVlowand
outVlow.
Videorecorder,photoprintersandespeciallyequippedcomputersareusedfor
documentation.Thecombinationofhighlymodernchargedcoupleddevice
(CCD)camerasandfullHDtechnologycaptureanddocumentthesurgical
procedures.
Dependingonhabitanduse,themajorityoftheequipmentisplacedeithernear
theheadorfootendofthepatientvis-a-visthesurgeon.TheuseofaVlexible
instrumentrackextendingfromthedrapes,whichcanlikewiseholdthe
monitors,isverypractical.Avoice-controlledcameraholderfacilitatesafatigue-
freepositioningofthecameraandthusoffersasafeworkingcondition.
Instruments(Basicequipment)
Until1960palpationprobesweretheonlyendoscopicinstrumentsavailable.
From1960-1970thediagnosisandtreatmentoffemaleinfertilityandlatertubal
sterilizationweretheonlyproceduresperformedbygynaecologicallaparoscopy.
� 6
Therefore,atraumaticforcepsandscissorsfortranssectionoftubesweretheVirst
instrumentstobedevelopedforlaparoscopy.
From1970onwards,thedemandforthermalcoagulationbegan.Electricalunits
werenotabletocatchaberrantelectriccurrencyasispossibletoday.In2012all
electro-surgicalunits-oncethedifferentandindifferentelectrodeshavebeen
correctlyapplied–recaptureaberrantelectricity.
Cave:Therehastobetotalcoverageoftheindifferentelectrodetotheskinof
thepatient.
Ofthemultitudeoflaparoscopicinstrumentsknowntoday,wedescribehereonly
aselectedfewwhichareabsolutelynecessaryforgynaecologicaloperative
laparoscopyandwhichshouldbeavailableinduplicateortriplicateonthe
instrumenttrolley.Multipleuseinstrumentsforcutting,grasping,dissection,
pushing,traction,coagulation,irrigationandsuctionareveryhelpful.
Instrumentsforperforation
• TheVeressneedle[3]isblindlyintroducedintotheabdomenafterlifting
theanteriorabdomenwall.Trocarsof3mm,7mm,10mm,12mm,15
mm,20mm,24mmdiameterareusedforguidingtheendoscopesand
operativeinstruments,irrigation,coagulationandduringemploymentof
needleholdersandmorcellators.• Thesimpleautomatic>lapvalvescanleakbecauseofsoilingwithblood
ortissueparticles.Thereforetheyaretobeusedforsingleuseonly.
Trumpetvalvesarestable,butmustbealwaysopenedandclosed.They
hindertheintroductionofneedlesandthread.• Endoscopiclensesmustbefrequentlywashedandremovedbecauseof
soilingduringtheoperation.Therefore,forsuchtrocarswereluctantly
useautomaticvalve,butprefertrumpetvalve.• PrimarytrocarscanbeinsertedbytheZ-puncturetechniquetoprevent
dehiscenceofaponeurosisandlateprolapseoftheomentum.The
decision,however,dependsonthesurgeon.Werecommendtheconical
trocars;butareawarethatthepyramidaltrocars,especiallyintheso-
� 7
calledsafetytrocars,areemployedasopticaltrocars.Theycarrythe
advantageofasharpcuttingedge(Fig.4).
�
Figure 4: Optics, trocars, needle holder and RoBi® instruments – rotating bipolar grasping forceps and scissors
(Karl Storz)
• OptiviewRbyEthicon(EthiconEndo-Surgery,Cincinnati,USA),VisiportR
byCovidien(MansVield,MA,USA)andXCelbyEthicon(Fig.5)offer
insertionundervision.Atpresent,only10mmto11mmtrocarsare
availablethroughwhichthe10mmlaparoscopecanbepassedunder
directvision.
� 8
�
Figure5:Xcel,adisposable,viewingtrocarforlaparoscopicentryundersight(Ethicon)
• OpticalVeressneedlescanbeinsertedundervision.Theinsertionunder
visioncanbedonebelowleftcostalmarginalso;asuitabletrocarcan
insertedthroughtheumbilicusundervision.• Thelinearexpansiontrocarshelpcontrolledwideningofanarrowcanal
byserialdilatation.• TheEndo-Tip.
DilatationInstruments
Itispossibletodilateupto10mm,12mm,15mmand20mmthroughan
introducedrodandasuitable5mmthreadedtrocar(Fig.6).
� Figure6: Dilatationinstruments:
a)Centralintroductionrod
b)Dilators
c)Mandrin,whenthedilatorisintroducedastrocar
Holding,GraspingInstrumentsandScrews
Varioustypesoftraumaticandatraumaticforcepsareusedasendoscopic
graspingtoolsforoperations(Fig.7).
� 9
� Figure7: Holding,graspinganddrillinginstruments:
a)Atraumaticforceps
b)Varioustipsofforceps(lefttoright):2intestinalforceps,lymphnodeholding
forceps,2biopsyforceps,spoonforcepsandtoothedforceps
c)Swabholder,beforeholdingandwiththeswab
d)Myomascrew
Theyarein5to20mmsizes.In10mmsizewerecommendthebigtoothed
forcepsandlymphnodeholdingforcepstoholdthetissuesVirmly.The10mm
swabholdingforcepsaresuitableforholdingtissueslightlyandforpushing.The
5mmand10mmswabholdersareusedintissuedissection.The5and10mm
myomascrewisusedfortractiononthemyoma.ThehandlesshowninFig.7are
roundgriphandles;however,thehandlesoftheRobiinstrumentsoftheKarl
Storzcompanyareeasierandmoreergonomictouse(Fig.4).
CuttingInstruments
5mmcurvedscissorsandthe5and11mmsaw-toothedscissorsaswellas
differentmicrokniveswithchangeabledisposablebladesareavailableas
doubled-edgedmodels(Fig.8).
� 10
� Figure8: Cuttinginstruments:
a)Dissectionscissorswithroundhandle,asmacroandmicroscissors(with2
mmspan)
b)Scalpel
c)Changeablecuttingblades(singleuse)ofthescalpel
Mostly,curvedscissorsareused,butroundscissorswithelectricconnectionare
frequentlyemployedbecauseoftheirextremesafety.Thelatteroneisoftenused
asadisposableinstrument.Bluntroundscissorsareespeciallysuitablefor
retroperitonealdissection.
SuctionandIrrigationInstruments
ThesuctionirrigationdevicesofKarlStorzandWisapGmbH(Sauerlach,
Germany)arewellknown.ThesystemofWisaphas5mmand10mmsuctionand
irrigationtubes(Fig.9).
� Figure9: Suctionandirrigationinstruments:
a)5mmsuctionirrigationcannulawithopenend
b)5mmsuctionirrigationcannulawithperforatedend
c)Aspirationcannulaforcysts
d)ManualaspirationsystemforDouglasexudates
� 11
Thesuctioncannulaisusedeitherwithanopentiporwithaperforatedtip.
LargevolumesofVluidsinovariantumorsandascitesareaspiratedwiththese
suctionirrigationcannula(Fig.10).
� Figure10:Suctionirrigationsystem(R.Wolf,Knittlingen,Germany)
Itissetatanirrigationpressureofupto300mmHgandanaspirationforceof
upto1bar.Thenormalsuctionforceismaximum800mbar;irrigationpressure
is300mmHg.Withextra-long(50cm)suctionirrigationtubes,itispossibleto
suckevenunderthedomeofdiaphragmfromthepelvicregion.Manydisposable
systemsarealsoavailable.
MorcellationInstruments
Thedevelopmentofmorcellationinstrumentswasslow.Inovarianresectionand
enucleationofmyoma,thetissueiscutwithscissorsandknives,dependingon
thesize.Thespecimencanberemovedeitherwithbig-toothedforcepsdirectly
throughthe11mmor15mmtrocarwithconicalend.However,theso-called
motordrivemorcellatorsin10mm,15mmand20mmdiametersareelectrically
poweredandfunctionwell.Thetissueisslowlycutelectrically,nearlyshaved
fromthesurface,andpulledintothetrocarsleeve.Itisparticularlysuitablefor
horizontaloperationsasinverticalusealacerationofbowelorvesselscaneasily
� 12
occur.KarlStorzproducestheSteinermorcellatorR,theRotocutandanew
development,theSawalheIISupercutmorcellator,allwithatissueprotection
shield(Figs.11&12).
� Figure11:ROTOCUTGI(KarlStorz),morcellationtoolwithprotectiveshield,availablein2sizes
(12and15mm)
�
Figure12:SAWALHEIISUPERCUTMorcellator(KarlStorz)
� 13
Manycompanieshavedisposablemorcellators.TheWISAPelectricmorcellator
wastheVirstontheinternationalmarket.Alternatively,thesurgicalspecimen
fromtheabdominalcavityisputinanendobag(smallplasticbags)withforceps.
Morcellationisonlyadvisedatpresentforbenignspecimens.However,Iforesee
thetransformationofVibroid-likematerialintopowder,whichcanthenbe
aspiratedandexaminedbythemolecularpathologistformalignancy.
InstrumentsforHemostasis
InstrumentsfortyingthebloodvesselssuchastheRoederloop,theendoligature
ortheendosutureswithextraorintracorporealknottingarewidelyknown(Fig.
13).Needleholdersforstraight,curvedorSkineedlesmustbeavailablein
differentvariations.Furtherdetailsaregiveninaseparatechapteronsuturesin
thismanual.
Forhemostasis,endocoagulation,[4]heatdenaturationat100-1200C,bipolar
coagulationinvariousforms(seesectiononenergysourcesinthischapter)and
monopolarneedle,meltinghook,highfrequencyscissorsorotherinstruments
aresuitable.Thegentlestmethodsareendocoagulationat1000Candbipolar
coagulation.Forlocalizedischemiaavasopressinderivativeinadilutionof1to
100isinjectedsubcapsularwithanapplicator.Thehaemostasisischemiaset
showninFig.13maybeusedoralternativelytheVeressneedlecanbeinserted
inaseparateabdominalincisiontoinjecttheVasopressindilution.
� Figure13:Instrumentsforhemostasis
� 14
Gynaecologistsprefersuturingandcoagulationdevices.However,clipsand
staplingdevices,whicharemorefrequentlyusedbygeneralsurgeons,arealso
usedforVixingmeshes,forpelvicVloorsurgery,lymphadenectomyand
hysterectomyinourVield.BothEthicon,aJohnson&Johnsoncompany(New
Bunswick,NJ,USA),andCovidienhavefascinatingdevicesonthemarket.Letme
justmentionhereCovidien’snewEndoClipApplicatorIII(5mm)witheasily
placedclipsandadigitalclipcounter(Fig.14)
� Figure14:EndoGIA™UltraUniversalStapler(Covidien)
andtheEndoGIA™Stapler(Fig.15&16).
� Figure15:EndoGIA™ReloadswithTri-Staple™Technology(Covidien)
� 15
�
Figure16:EndoGIA™UltraUniversalStapler(Covidien)
InstrumentsforClampingLargeVessels,EmergencyNeedle
Emergencyinstrumentsandtheusualclampsusedinroutinegynaecological
operationsshouldnotbeusedforclampingthevessels.Vascularclampsmustbe
readilyavailable(Fig.17).
� Figure17: Vascularclamps:
a)Emergencyneedle
b)Vascularclampswithdifferenttips
Largevesselinjurymustbeimmediatelyexploredbylaparotomyandthe
bleedingvesselclamped.Ifavesselintheanteriorabdominalwallisinjured
(epigastricartery),itisadvisabletoligateitatanappropriateplacewithalarge
emergencyneedle.
� 16
InstrumentsforDrainage
TheRobinsondrainageissuitable(Fig.18).forabdominaldrainage.
� Figure18:Robinsondrainage.Theperforatedendofthecannulaisintroducedwitha5mm
trocarandplacedinthedeepestpartoftheabdominalcavity.ThedrainagebottleisVixedtothe
patient’sthighandcollectsthedrainedVluids.
Itworksonagravitybasisandasarulecanbeleftinsituover24hours.The
blindinsertionofthesecondarytrocarisobsolete.Nowadays,theinsertionis
carriedoutundervisionaftermakingasubumbilicallongitudinalskinincision
withtheknifeheldparalleltotheabdominalwall.
CAVE:Fatalitieshavebeenreportedbyaccidentalslittingoftheaorta.
BeforeinsertionoftheVeressneedle,whichisalwaysblind,itisadvisableto
followthesafetymeasuresdescribedinthechapteronAbdominalAccessin
thisbook.
InstrumentsforUterineManipulation
Vacuumintracervicalprobesinthestandardthreesizesallowonlypartial
movementoftheuterusandfacilitatetubalchrompertubation.
Variousinstrumentsforintrauterinemanipulationmakeitpossibletomobilize
theuterus.TheuteruscanbeanteVlexed,retroVlexed,laterallymobilizedand
rotated.Someuterinemanipulatorsallowthepossibilityofchromopertubation.
UterinemanipulationisrequiredinendometriosisofthepouchofDouglas,for
hysterectomies,inbladderdomeendometriosisandforenucleationofmyoma.
TheACE(AbdominalCavityExpander)servestoelevatetheanteriorabdominal
wallincaseswithadhesions.Furtherversionsofthisprincipleareusedinthe
gaslesslaparoscopy,e.g.asLaparoliftR.
� 17
TheHohl,theMangeshikarandtheDonnezintra–uterinemanipulatorsor
mobilizersaswellastheKonincxkuterinetwisterareallproducedbyKarlStorz
andhaveacupwithawellpalpableandvisiblebordertovisualizetheresection
levelbetweenvaginaandcervixforallcasesofTLH(TotalLaparoscopic
Hysterectomy)(Fig.19).
� Figure19:IntrauterinemanipulatorsproducedbyKarlStorzaccordingtoKoninckx,Clermont-
Ferrand,Mangeshikar,Hohl,DonnezandTintara
ThisfacilitatestheintracervicalapproachofTLH;however,theyarenottobe
usedfortheextracervicalapproachandinoncologiccasesofhysterectomy.Many
companieshavedisposablemanipulators.
� 18
Subtotalhysterectomy,asCISH(ClassicIntrafascialSupracervicalHysterectomy)
orLASH(LaparoscopicAssistedSupracervicalHysterectomy),isfacilitatedbythe
useofanelectricloopproducedbyLiNAMedicalApS,Glostrup,Denmark(Fig.20
&21)astheLiNALoop,byKarlStorzastheStorzLoopandbyBOWAasthe
BOWAloop.
� Figure20:LiNALoop(LiNAMedical)
�
Figure21:LiNALoopatsubtotalhysterectomy
� 19
LensesandEndoscopes
ScopesareavailableinrigidandVlexiblesystems(Fig.22).
A)
�
B)
�
Figure22: Endoscopes:
A:Rigidstandardlaparoscope(10mm)with30°optic(a)andwith0°optic(b)
B:Flexibleendoscope
TherigidsystemisbasedonHopkins’sexperiencewitharodlenssystem,which
resultsingoodresolutionanddepthoffocusratio[5].Flexibleendoscopesare
basedontheuseofopticalVibrebundles.Therigidlaparoscopesarein3mmto
11mmsizes,e.g.thearthroscopewitha140angle.Mostoftherigidendoscopes
aredirectlyconnectedtothetelescopethroughthecameracouplingsystem.The
pictureisenlargedsothatitlooksevenbiggeronthemonitor.InVlexible
endoscopes,thebundleofVibresisalsoenlarged.Thestandardlaparoscopesare
rigidinstrumentswitha00lens.The300lenshastheadvantageofawide
panoramicview.WiththeEndo-Cameleon(KarlStorz)a120degreepanoramic
viewispossible(Fig.3).
� 20
Eachcamerahastwocomponents:headandcontrol.A35mmcouplingsystem
yieldsamuchmoreenlargedpicturethana28mmcoupler.Adirectcoupling
transmitsthepicturedirectlytothecamera.
OlympusSurgical(Hamburg,Germany)offersdifferentVlexibleendoscopesas
wellasrigidendoscopeswithVlexibletips,afour-wayangulationsystemanda
miniaturizedCCDchipattheinstrument’stip(Fig.23).
� Figure23:EndoEYEvideolaparoscope(Olympus)
Withthechiponthetipoftheoptictheobservationlightpassesthroughfewer
lensesthanonarigidscope.Thisallowsbrighterandsharperimagesthanwhen
thecameraisattachedtotheheadoftheoptic.
EnergySystemsforOperativeLaparoscopy(Electrosurgeryand
Thermofusion)
Electrosurgery
Ohm’slaw,V=IxR.(Voltage=CurrentxResistance)isdescribedintermsof
current,voltageandresistance.Electrosection,i.e.cuttingoftissuebetweenthe
activeelectrodeandthetissuewhereanelectricalarcisgenerated,takesplace
above2000C.Duringcoagulationanddesiccationthetissueisheatedslowly.It
resultsindenaturation,evaporationofwaterandsecondaryhemostasis.The
argonbeamcoagulatorisamonopolarelectrosurgicalinstrument.Inprinciple,
non-combustibleargongas(4L/min)acrossanelectrodecannulaactsasabridge
� 21
forelectricalcurrenttoburnthetissuesuperVicially(upto5mmdepth)[6].As
thegasiseasiertoionizethanair,electricalarcsdevelopupto1cmabovethe
tissuesurface.Inmonopolarelectrosurgery,high-densitycurrentisusedatthe
activeelectrodethatisconductedtothepatientontouching.Inbipolar
electrosurgery,twosmallelectrodesofsamesizeareusedwhichlieclosetoeach
otherandfunctionasactivepassiveelectrodes.
Thermaltechniques,suchasultrasoundcoagulation,laseraswellasclipsand
suturingtechniquescanachieveendoscopichemostasis.Whiletheuseofthermal
hemostasisgoesbacktotheglowingiron,accordingtoPaquelin,the
developmentofsafehighfrequencycurrenttechniquestook40years.The
applicationofthelasertechnique,ultrasoniccuttingandcoagulationtechniques
andthelocalthermaleffects,suchasthermocoagulation,takeplaceintherange
of80to1200C.Suturingandcliptechniquesarehandledinnextchapter.
Wedifferentiatebetweenfulgurationandcoagulationinhighfrequency
hemostasis.Infulguration,electromagneticoscillationsacrossanairbridge
produceradiofrequencybetweenthetipoftheelectrodeandthesurfaceofthe
organ,i.e.theycomeindirectcontact.Thegeneratedheatislimitedtotissue
surface,i.e.theareavisiblethroughthescope.Bycoagulationwemeanthe
heatingofthetissuesuntilintracellularwaterboilsundertheinVluenceofhigh
frequencycurrent.
Inadditiontothetechniqueusedforfulgurationandforcoagulation,themost
importanttechniqueinmedicineandendoscopicsurgeryistheelectrotomy,the
cuttingoftissuewiththeso-calledelectricalknifeortheelectricalloop.The
sustainedintermittentorunidirectionalhighfrequencycurrent,whichcanbe
producedwithtubesortransistorgenerator,producessmooth-edgedcuts.In
bipolarhighfrequencycurrentthereistissuedestructionbetweenthepolesor
theircontactpoints.Inmonopolarcurrent,thecurrentsurgearisingatthetipof
theinstrumentisusedforcuttingandgeneratingheatforcoagulation.
Semmdevelopedvarioussystemstocontroltheenergyoutputduringcontrolled
endocoagulation.ThecontrolunitoftheEndocoagulatorR(WISAPcompany)is
� 22
switchedonoroffbyapneumaticfootswitch,i.e.withoutelectricity.Thedesired
temperatureforcoagulationcanbepresetbetween900and1200Cjustlikethe
acousticallysignalledcoagulationtime.Theheatedmetalmassisreducedtoa
minimuminthethreeinstruments,pointcoagulator,crocodileforcepsand
myomaenucleator,sothattheinstrumentscooloffimmediatelyafterheating.
Deepburnsarenotcausediftheintestinesaretouchedaccidentlybecausethe
thermalenergyistoolowtoemitmuchheat.Thecoagulationeffectsin
endocoagulationproduceextensivecauterization.Theyarenotselectively
controllable.
Atpresentevenwithhighfrequencyinstrumentsthereisnoblindand
uncontrolledburningbecauseoftheelectricalsystemcontrol.Therefore,weuse
monopolarcurrentforcuttingandbipolarinstrumentswhencoagulationis
requiredbeforecuttingbigvesselsinendoscopicsurgery.Mostofthesystems
haveanautostop,sothatonlytherequiredtissueisdenatured.Itisnotsetfora
verybigcoagulationzone.
Bi-ClampforvaginalandopensurgeryandBiCision(Fig.24)forlaparoscopic
surgeryarethethermofusiondevicesofErbeElektromedizinGmbH(Tübingen,
Germany).
� Figure24:BiCisioncoagulationandcuttingforceps(Erbe)
� 23
Theireffectiselectronicallycontrolledthermofusionandthemechanical
separationoftissue.
TheelectrocoagulationsystemofErbe(Fig.25)usesanadditionalargonbeamer,
controlledbyafootswitch,whichfacilitateslinearcoagulationbyswitchingon
theargongas.Thisgynaecologicalworkstationwiththehighfrequencymodule
VIO300Dcanbeconnectedtoanymonopolarorbipolarcoagulationdevice.It
containsseveralmodules,suchastheargonplasmacoagulation(APC2)andthe
smokeplumeevacuator(IES2).
� Figure25:ErbeGynaecologicalWorkstationVIO300D
TheErbeelectrosurgicalunit(ESU)hasacolourmonitordisplaythatprovides
theuserwithanon-screentutorialaswellassettingsandoperational
information.TheunithasvariouscuttingandcoagulationmodeswithdeVined
effectlevelstoprovidethephysicianVlexibilityininterventionalapplications(i.e.
itsabilitytogenerateHFcurrent).Thesystemhasautomaticstartandstop
features.Theequipmentisprogrammableandvariousaccessories(e.g.
footswitches,handinstruments,etc.)aswellasmodesmaybeassignedto
� 24
performspeciVicfunctions.Uponactivation,theenergydelivered(inwatts)from
theESUtothetissueisdisplayedonthedisplayscreen.
TheuseofheatinmicrosurgerycanbetracedbacktoHippocrateswhousedheat
toburnacarcinomatousgrowthintheneck.Heatingthetissueabove450C
causesirreparablecellulardamage.Tissuedenaturationsetsinat450Cand
heatingabove1000Cleadstotypicaldesiccationwithhaemostasis.Temperatures
above2000Cproducecarbonizationanddisintegration.
Bipolarvesselsealing,alsodescribedasthermofusion,combinedwithpressure
betweenthebranchesoftheinstruments,isanew,easytousetechniquethat
hasbeenpickedupbymanycompaniesintheproductionofdisposable
instrumentswithintegratedcuttingdevicessuchasLigaSure(Covidien)(Fig.26
&27).
� Figure26:LigaSure(Covidien),bipolarvesselsealingsystem,10mm(Atlas)and5mm
� 25
�
Figure27:LigaSure(Covidien)jawprovidingacombinationofpressureand
energytocreatevesselfusion
TheNightknife(BOWA-electronicGmbH,Gomaringen,Germany)(Fig.28)isa
bipolarvesselsealingdevice.Theinstrumentincorporatesatraumatictipsfor
securedissectingandsealing.Theintegratedcuttingsystemsaveschanging
instrumentsfortissueseparation.
� Figure28:Nightknife(BOWA-electronic)
� 26
TheGyrusPK(Olympus)technologydeliversaproprietary,pulsingultra-low
(110V)andhigh-currentRFenergywaveformtocreateabroadrangeoftissue
effects,andallowsthetissueanddevicetiptocoolduringthe“energyoff”phase,
minimisingstickingandcharring(Fig.29a,b).
� Figure29a:GyrusPKintegratedvesselsealingandcuttingsystem(Olympus)
� Figure29b:GyrusPKcontrolunit(Olympus)
Bymeansofthesmartelectrodetechnology,theENSEALsealinginstrument
(EthiconEndo-Surgery,)permitssimultaneoussealingandthepossibilityof
� 27
tissueseparation,includingvesselsupto7mm(Fig.30).Thetipofthe
instrumenthaseithera5mmroundtipora3mmslightlycurvedtipenabling
tissuepreparationandsealing.
� Figure30:ENSEALsealinginstrument(EthiconEndo-Surgery)
Laser
Laserbeamisoftendescribedas“lightthatheals.”LaserisanacronymforLight
AmpliVicationbyStimulatedEmissionofRadiation.FoxestablishedtheVirst
surgicallaserin1960.Bruhatandhiscolleaguesin1979andTadirand
colleaguesin1996introducedCO2laserinlaparoscopy.Today,thereare
enthusiastsoflasersurgery[7,8]andenthusiastsofelectrosurgery.Lightenergy
isampliViedtogenerateincreasedcoherentelectromagneticradiation.Herewe
mentionthethreeformsoflaserusedinendoscopicsurgery:• CO2-laser• Nd:YAG-laser• KTP-lasers
TheNeodymium:Yttrium-Aluminium-Garnet(Nd:YAG-)laser,theArgonlaser
andKTP-(Potassium-Titanium-phosphate-)laserareusedforcuttingand
coagulation.Allthetissueeffectsareproducedbecauseofthecontinuousor
pulsingthermodynamicconversionoflightinthermalenergy.Becauseofthe150
refractionofthelaserbeamafterarisingfromtheVibrebundle,theeffectcanbe
� 28
achievedonlyupto2cmfromthetipoftheVibres.In1996Wallwieneretal.
introducedlasertreatmentintoreproductivesurgery[8].
Endocoagulation
Likethehotplate,endocoagulationtakesplaceascontactcoagulation,aheat
denaturationbylowvoltage.Awidercoagulationcanbemoreeasilyemployedas
comparedtopointcoagulation.Thecontrolunitheatsthreetypesofprobes:• PointcoagulatorforspeciVic,focalhemostasis• Crocodileforcepsforcoagulationoftubes• Myomascrewfordissectionandenucleationofmyomata.
ThesedevicesareproducedbyWisapbutinthepracticalapplicationarealready
historic.Weusedthemfrom1970-2000intheKielSchoolofGynaecological
Endoscopy.Varioussimilardevicesusingtheideaoflocalheatproductionare
appearingonthemarkettoday.
HarmonicScalpel-UltrasonicEnergy
Theharmonicscalpelisanultrasonicallyactivatedlaparoscopicinstrumentthat
usesmechanicalenergytocutandcoagulatetissues.Today,theharmonicscalpel
canbeusedas5to10mmcuttingbladesandscissors.Activationofthetitanium
bladetakesplacebyapiezoelectriccrystalwithafrequencyof55500cyclesper
secondinthehandset.Thecuttingandcoagulationeffectsarecomparableto
thatoftheCO2-laser[9].Thelateralthermaldamageislessthanbyhigh
frequencycoagulation.Burningandcarbonizationoftissuesarenotobserved.
Theadvantagesofultrasoundenergyinsurgicalendoscopicinstruments
producedbyEthiconEndo-SurgeryandOlympusarewellknowntodayand
highlyappreciated.AsanexampleletusfocusontheharmonicaceofEthicon
(Fig.31)whichwithitsspeciViccontrolunit(Fig.32)allowsashorteranda
longereffectofsealing.Themechanicalenergyworkswithlowtemperatures,
smalllateraldamageandminimaldesiccationofthetissue.Theenergyisapplied
paralleltopressurethusminimizingtissuetrauma.Thesimultaneouscutting
andcoagulationgivesagoodbalancebetweenhemostasisandcutting.AdeVinite
� 29
coagulationofvesselsupto2mmisguaranteed.Precisedissection,cuttingand
coagulationaresecuredwithoutthepatientcomingintocontactwithelectricity.
� Figure31:HarmonicAceforceps(Ethicon)
� Figure32:HarmonicAcecontrolunit(Ethicon)
Anew5mmcoagulationandcuttingdevice,“Thunderbeat”fromOlympus,
combinesthermofusionandultrasoundtechnologyandincreasessurgicalspeed
andprecision(Fig.33).
� Figure33:“Thunderbeat”forceps(Olympus)
� 30
Thedifferentharmonicinstrumentsonthemarkettoday,suchasharmonic
shears,forcepsandcuttingrings,areappliedforadhesiolysisaswellasanytype
ofadenexectomy,ovarectomyandhysterectomy.Itremainsuptothesurgeon
whetherheusesthemincombinationwithothersealinginstrumentsorbipolar
coagulation.
Microendoscopy
Byrigorouslyfollowingtheconceptofminimallyinvasiveaccessforhysteroscopy
andlaparoscopy,advancesininstrumentdesigninghaveledtoopticsystems
measuringonlyabout1.8to2mmincludingthetrocarsurroundingthem.Phase
opticandlensopticsystemwithdiameterbetween1.2mmand2mmareoffered
byinstrumentmanufacturers.Inallsystemsthelaparoscopecanbepassed
throughtheVeressneedleorthesleeve.Additionaltrocarinsertionaftergas
insufVlationisthereforesuperVluous.However,comparedtothestandard5mm
and10mmoptics,eventhemostsatisfactoryofthemini-systemsshowsdeVicient
lightingefViciency.Theinstrumenttrocarsarealsoavailableincorrespondingly
smalldiameters.
Themeritsofminimaloperativetraumaandtheavoidanceofumbilicaltrocar
insertionachievedbyinsertingthelaparoscopethroughtheVeresscannulain
minilaparoscopiesusedtohavedisadvantages,suchasthemechanicalfragilityof
theminilaparoscopesanddifVicultoperativesiteswitharestrictedview. Todaynewopticsandstabileinstrumentshavevirtuallyeliminatedthese
disadvantages.Therefore,asetofminilaparoscopicinstrumentsmustalwaysbe
availableforuseincertainsurgicalinterventions.Thesmalldiameterofthemini-
instrumentscontributestowardsreducingtraumaandpaininchildrenandin
smallersurgicalprocedures.
RoboticEndoscopicSurgery
Amongthecurrentavailableroboticsystemsandinstruments,thedaVincirobot
hasprovedtobethemostadvancedsurgicalsystem.Otherroboticsystems,such
astheTelelapALF-X,arenotyetusedinthetreatmentofpatients.
� 31
ThedaVincihasbeenverysuccessfullyappliedinoncologicsurgeryand
facilitatesafasterlearningcurveforlaparoscopists.
Aliteraturesurveyonrobotic-assistedgynecologicaloncologyclearlysupports
theuseofthedaVincisurgicalsysteminlaparoscopiconcologicalsurgery.
Roboticprecisionintumorexcision,easierintracorporalsuturingandfavourable
ergonomicsforthesurgeonmakethedaVincirobotparticularlysuitablefor
performingcomplexlaparoscopic,microinvasivesurgicaloperationsin
gynecologicaloncology.
Roboticsurgerycombinestheadvantagesofopensurgeryandendoscopic
surgery.ThedevelopmentofthedaVinciinthetreatmentofpatients
encompassesnearly10yearsandshowscontinuousimprovementsin
applicationforurologists,generalsurgeons,cardiacsurgeonsandgynaecological
surgeons(10-12).
Fig.34showsthelatestdaVincisurgicalconsoleanddockingstationandFig.35
theEndoWrist®instruments.
� Figure34:daVinciSurgicalSystemSi,integratedroboticsystemwith
workingconsole,sidecartandcontrolunit(IntuitiveSurgical)
�
Figure35:EndoWrist®instrumentsofdaVinciSurgicalSystem
� 32
Today,adualconsoleisavailablewhichallowstwosurgeonstocollaborate
duringaprocedure.Theadvantagesofthesysteminclude3DHDvisualization,
anintegratedsurgeontouchpadwhichofferscomprehensivecontrolof
recordingsandanextensivearrayofwristedEndoWrist®instrumentswith
Vingertipcontrolsandfootswitchperformanceofvarioustasks,suchas
applicationofenergyinstruments,etc.Amotorizedpatientcartfacilitatesquick
andcontrolleddockingofthesystemtothepatient.
TheItalianroboticsystemcalledTelelapALF-X(Fig.36-38)incorporatesaneye-
trackingsystem,forcefeedbackcharacteristics,andismanagedbyonesurgeon
sittingunsterileatacomputerconsoleandanassistantinteractingwiththe
roboticarmsofthesecondconsole(4)whichcanbeeasilymovedaroundthe
table.Asasafetyfunction,thesystemstopswhenthesurgeonsceasestolookat
theoperationsiteonthecomputerscreen.Activationofanygiveninstrumentis
performedbygazingattherespectiveicononthescreen.Eachpointthesurgeon
looksatmovestothescreen’scentre.3Dstereovisionsimulatesthevisionof
opensurgery.
� Figure36:TelelapALF-Xattheoperationtable(Sofar)
� 33
� Figure37:TelelapALF-Xcontrolunit(Sofar)
� Figure38:TelelapALF-Xunitformeasuringtrocarforce(Sofar)
� 34
ArticulatedInstruments
TheTerumoKymeraxSystemorTerumo“Precision-DriveArticulatingInstrument”
Anewmotor-driven,handheldsystemthatoffersprecision-drivenarticulating
instruments,calledtheTerumoKymeraxSystem(Terumo,Tokyo,Japan),has
recentlybeenintroducedontothemedicalmarketinEurope(Fig.39).
� Figure39:TerumoKymeraxSystemwithcontrolunitandbilateral articulatedinstruments
TheSystem:Thethreecomponentsincludeaconsole,ahandleand
interchangeableinstruments.Uptotwohandlescanbeconnectedtotheconsole,
whichprovidespowertothemotorslocatedwithinthehandlecomponentofthe
system.TheinstrumentisusedunderdirectsurgeoncontrolattheORtable,is
handheld,andcanbeusedinconjunctionwithconventionallaparoscopic
instruments.
Instruments:Theinstrumentsavailableincludeaneedledriver,monopolarL-
hookcautery,monopolarscissorsandMarylandgrasperanddissector.The
instruments’functionsaresuitedforperforminggeneralsurgicaltaskssuchas
manipulatingtissue,ligating,suturing,knottying,cutting,coagulatingand
dissecting(Fig.40).
� 35
� Figure40::PossibilitiesofinstrumentrotationwithintheTerumoKymeraxSSystem
Features&Bene>its:Thetiparticulationiscomputer-assistedandallowsthe
surgeontocontrolthemovementsthroughindividualyawandrollcontrolson
thehandle’sinterface.Thespeedofthemovementscanbeadjustedtosuiteach
individualsurgeon’spreference.
Theprecision-drivearticulatinginstrumentprovidesanadditional2degreesof
freedom(yawandrolloftheinstrumenttip,independentoftheshaft)tothe4
degreesoffreedomallowedbystandardlaparoscopicinstruments(pitch,yaw,
rollandsurge).ThearticulationallowstheinstrumentstoefVicientlyadjustthe
instrumenttipanglestothedesiredtissueplanesforVinedissectionand
cauterizationoftissuewhilemaintainingergonomichandpositioning.The
articulationalsofacilitatessuturingbyprovidingtheoperatorwiththeabilityto
adjusttheanglesforsutureplacementintheidealtissuepositionattheoptimal
angle.Theopeningandclosingofthejawsorbladesaremanuallycontrolled
throughatriggeronthehandle.Thismanualfunctionprovidestheoperator
withbeneVicialhapticfeedback:
1)Roll:160degreeseachway(totalof320degrees)
2)Yaw(movementofleftandright):70degreeseachway(totalof140degrees).
� 36
Theadvantagesofthearticulatedinstrumentscomparedtoroboticsarethe
following:• Portability• Bythebedside• Canbeusedinconjunctionwithregularlaparoscopicinstruments• Willnotcostafortune• Precisemovementofthetip• Easytocontroltipmovementbythepushingthebuttononthehandle• Ergonomichandle(angleofwristandpositionofVingers)
2)Ther2DRIVEandr2CURVE
Theseinstrumentsaredisposableandarticulatedinstrumentsandtheiruseis
becomingmorewidespread.ThisTübingensetofinstruments(Tuebingen
ScientiVicMedicalGmbH,Tuebingen,Germany)wasdevelopedbyGerhardBues,
acreativegeneralendoscopicsurgeon.
r2DRIVE is ahand-held instrument that offers all thedegreesof freedomof a
robotic system. Due to the 90° deVlectable and inVinite rotatable tip, in
combination with the inVinite rotatable shaft, surgical manoeuvres can be
conVidentlyandpreciselycarriedoutevenindifVicultanglesandtightspaces.
TheinstrumentisprimarilycontrolledwiththeVingertips,therebyoffering
utmostprecisionandcomfortforthesurgeon.Extensivemovementsarethus
renderedsuperVluous,whichobviatesfatigueanddiscomfortonthepartofthe
surgeon.
Theshaftdiameteris5mm,enablingbodyaccessthroughsmallincisions.
BipolarHF-technologyprovidessecure,reproducibleandclearlydeVinedeffects
inpreparationandhemostasis.Theinstrumentisavailableinvarious
conVigurations:atraumaticforceps,needleholder,dissectorandscissors.Ther2
DRIVEisadisposable,one-pieceinstrument(Fig.41a,b).
� 37
� Figure41a:r2DRIVEhand-heldinstrument,lefthand(TübingenScientiVic
Medical)
� Figure41b:r2DRIVEhand-heldinstrument,righthand(TübingenScientiVicMedical)
Ther2CURVEisahand-heldinstrumenttobeusedatsingleportentrythat
offersalldegreesoffreedomofaroboticsystemwithaspecialdesigntosupport
singleportsurgery(Fig.42).
� Figure42::r2CURVEhand-heldinstruments(TübingenScientiVicMedical)
� 38
Theuniquedesignoftheinstrumentsallowseasyandcontrolledhandlingand
preciseandreliablenavigationandmanoeuvrability.Thecombinationofthe
curvedshaftwiththe360°inVinitetiprotation,thetipdeVlectionandthefulland
inViniteshaftrotationgivesthefreedomneededtoperformsingleportsurgery
(Fig.43).NoswordVighting;nocrossover;nomirroredviews.
� Figure43:r2CURVEscissortip(TübingenScientiVicMedical)
Theinstrumentoffersashaftdiameterof5mmandbipolarHF-technology.The
instrumentisavailableinvariousconVigurations:atraumaticforceps,needle
holder,dissectorandscissors.Ther2CURVEisadisposable,one-piece
instrument.
Singleportendoscopicentry
Laparoscopyinthe1940sstartedwiththeangledlaparoscope(opticandone
workingchannel)ofRaoulPalmerinFranceasSEL.Laparoscopyatthattime
wasmainlyusedfordiagnosticpurposesandforsterilizations.KurtSemmin
Germanyfurtherdevelopedtheprocedureintooperativelaparoscopybyusing
multipleentriesandinstruments.Semmcalledtheprocedure“pelviscopy”,to
differentiatethetechniquefromthesimpleliverbiopsiesthattheinternists
calledlaparoscopy,asthegynaecologistworksmainlyintheminorpelvis.Thus,
theinsurancecompaniesstartedtopayforthesegynaecologiclaparoscopic
proceduresinGermany.Withtheimprovedtechnologyoftoday,SELtakesthe
ideaoftheearlylaparoscopytonewhorizons.OfthemultitudeofSELports
available,letusmentiontwodisposableandonereusable:
� 39
1)TheSILSport(Covidien)(Fig.44)isadisposableport.Hereasiliconeportis
introducedintotheabdominalcavityusingaclassicalcurvedgrasperwithabeak
of5-6cm.ThesurgeonhasthechoiceoftwoportsofVivemmandoneallowing
foralargebarrelinstrumentof10-12mmoronewithfour5mmports.TheSILS,
withthepossibilitytointroducelargerinstruments,issuitablefor
hysterectomies.
� Figure44:SILS(Covidien)
2)AnotherdisposableportistheQuadPort(Fig.45)ofOlympuswhichcontains
duckbillvalvesandrequiresnogelforinsertion.Instrumentsof5,10,12and15
mmcanbeintroducedeasilyforergonomicsurgery.The5mmLESSEndoEYE
videolaparoscopeprovidesexcellentvisualisationandhelpstoavoidinstrument
clashing.
� Figure45:QuadPort(Olympus)
� 40
SpecialisedcurvedHiQ+LESSinstrumentsallowinternaltriangulationand
mimictraditionallaparoscopy(Figs.46&47).
� Figure46:LESSSystemwithEndoEYEandcurvedinstruments(Olympus)
�
Figure47:SevenvariationsofLESScurvedinstruments(Olympus)
� 41
3) The XCONE (Fig. 48) of Karl Storz is a reusable port. This system is
operational in the abdomen with 3 – 5 entry channels, one allowing
largebarrelinstruments.Usuallythe3or5mmopticisplacedintothe
middleentryandatleastonecurvedinstrumentontheleftorrightside.
� Figure48:XCONE(KarlStorz)
4)TheENDOCONE®(Fig.49)isaspecialaccesssystemdevelopedbythe
generalsurgeonCuschieriinwhichseveninstrumentscanbeintroduced
simultaneously
� Figure49:ENDOCONE®(KarlStorz)
� 42
DevelopmentsareongoingascanbeseenbytheETHOSSurgicalPlatform™
(EthosSurgical,Beaverton,USA),onwhichthesurgeonisposturedoverthe
midlineofthepatientwithoptimalporttriangulationoptions(Fig.50).
� Figure50:ETHOSSurgicalPlatform™(ETHOSSurgical)
Newinstrumentsandapparatusesarecontinuouslybeingappraised.Theyassist
thesurgeonbutdonotreplacehisknowledgeandhavealwaystobecritically
evaluatedandstudiedbeforetheyareapplied.
� 43
Figures
Figure1: SMARTCART:Equipmentcartforgynaecologicendoscopicsurgery
(laparoscopyandhysteroscopy)withelectrosurgicalunit,CO2
pneuautomaticwithheatedgas,lightsourceandHDTVmonitor
(KarlStorz3DSystem)aswellascontrolunitforhysteroscopic
surgery(KarlStorz)
Figure2: OR1™NEO(KarlStorz)withpanoramicviewing
possibilities,integratedcommandingfunctionsforalloperative
proceduresanddocumentation
Figure3: ENDOCAMELEON®laparoscope(KarlStorz)
Figure 4: Optics, trocars, needle holder and RoBi® instruments – rotating
bipolar grasping forceps and scissors (Karl Storz)
Figure5: Xcel,adisposable,viewingtrocarforlaparoscopicentryunder
sight(Ethicon)
Figure6: Dilatationinstruments:
a)Centralintroductionrod
b)Dilators
c)Mandrin,whenthedilatorisintroducedastrocar
Figure7: Holding,graspinganddrillinginstruments:
a)Atraumaticforceps
b)Varioustipsofforceps(lefttoright):2intestinalforceps,lymph
nodeholdingforceps,2biopsyforceps,spoonforcepsandtoothed
forceps
c)Swabholder,beforeholdingandwiththeswab
d)Myomascrew
Figure8: Cuttinginstruments:
� 44
a)Dissectionscissorswithroundhandle,asmacroand
microscissors(with2mmspan)
b)Scalpel
c)Changeablecuttingblades(singleuse)ofthescalpel
Figure9: Suctionandirrigationinstruments:
a)5mmsuctionirrigationcannulawithopenend
b)5mmsuctionirrigationcannulawithperforatedend
c)Aspirationcannulaforcysts
d)ManualaspirationsystemforDouglasexudates
Figure10: Suctionirrigationsystem(R.Wolf,Knittlingen,Germany)
Figure11: ROTOCUTGI(KarlStorz),morcellationtoolwithprotectiveshield,
availablein2sizes(12and15mm)
Figure12: SAWALHEIISUPERCUTMorcellator(KarlStorz)
Figure13: Instrumentsforhemostasis
Figure14: EndoGIA™UltraUniversalStapler(Covidien)
Figure15: EndoGIA™ReloadswithTri-Staple™Technology(Covidien)
Figure16: EndoGIA™UltraUniversalStapler(Covidien)
Figure17: Vascularclamps:
a)Emergencyneedle
b)Vascularclampswithdifferenttips
Figure18: Robinsondrainage.Theperforatedendofthecannulais
introducedwitha5mmtrocarandplacedinthedeepestpartof
� 45
theabdominalcavity.ThedrainagebottleisVixedtothepatient’s
thighandcollectsthedrainedVluids.
Figure19: IntrauterinemanipulatorsproducedbyKarlStorzaccordingto
Koninckx,Clermont-Ferrand,Mangeshikar,Hohl,Donnezand
Tintara
Figure20: LiNALoop(LiNAMedical)
Figure21: LiNALoopatsubtotalhysterectomy
Figure22: Endoscopes:
A:Rigidstandardlaparoscope(10mm)with30°optic(a)andwith
0°optic(b)
B:Flexibleendoscope
Figure23: EndoEYEvideolaparoscope(Olympus)
Figure24: BiCisioncoagulationandcuttingforceps(Erbe)
Figure25: ErbeGynaecologicalWorkstationVIO300D
Figure26: LigaSure(Covidien),bipolarvesselsealingsystem,10mm(Atlas)
and5mm
Figure27: LigaSure(Covidien)jawprovidingacombinationofpressureand
energytocreatevesselfusion
Figure28: Nightknife(BOWA-electronic)
Figure29a: GyrusPKintegratedvesselsealingandcuttingsystem(Olympus)
� 46
Figure29b: GyrusPKcontrolunit(Olympus)
Figure30: ENSEALsealinginstrument(EthiconEndo-Surgery)
Figure31: HarmonicAceforceps(Ethicon)
Figure32: HarmonicAcecontrolunit(Ethicon)
Figure34: daVinciSurgicalSystemSi,integratedroboticsystemwith
workingconsole,sidecartandcontrolunit(IntuitiveSurgical)
Figure35: EndoWrist®instrumentsofdaVinciSurgicalSystem
Figure35: TelelapALF-Xattheoperationtable(Sofar)
Figure36: TelelapALF-Xcontrolunit(Sofar)
Figure37: TelelapALF-Xunitformeasuringtrocarforce(Sofar)
Figure38: TerumoKymeraxSystemwithcontrolunitandbilateral
articulatedinstruments
Figure39: PossibilitiesofinstrumentrotationwithintheTerumoKymeraxS
System
Figure40a: r2DRIVEhand-heldinstrument,lefthand(TübingenScientiVic
Medical)
Figure40b: r2DRIVEhand-heldinstrument,righthand(TübingenScientiVic
Medical)
Figure41: r2CURVEhand-heldinstruments(TübingenScientiVicMedical)
� 47
Figure42: r2CURVEscissortip(TübingenScientiVicMedical)
Figure43: SILS(Covidien)
Figure44: QuadPort(Olympus)
Figure45: LESSSystemwithEndoEYEandcurvedinstruments(Olympus)
Figure46: SevenvariationsofLESScurvedinstruments(Olympus)
Figure47: XCONE(KarlStorz)
Figure48: ENDOCONE®(KarlStorz)
Figure49: ETHOSSurgicalPlatform™(ETHOSSurgical)
� 48
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theaidofaroboticassistant(thevoice-controlledopticholderAESOP)in
gynaecologicalendoscopicsurgery.HumReprod,1998.13(1O):p.
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2. Semm,K.,OperationslehrefürendoskopischeAbdominal-Chirurgie.1984,
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3. Veress,J.,NeuesInstrumentzurAusführungvonBrustoder
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6. Brill,A.I.,Energysystemsforoperativelaparoscopy.JAmAssocGynecol
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9. Schemmel,M.,etal.,ComparisonoftheultrasonicscalpeltoCO2laserand
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10. AdvinculaAP,WangK.Evolvingroleandcurrentstateofroboticsin
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� 49
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