Contents Introduction 271 Laparoscopic Instrumentation 271 Instruments for Laparoscopic Access 271 Transperitoneal Access 271 Retroperitoneal Access 273 Laparoscopic Trocars 274 Types of Trocars 274 Sites for Trocar Placement 274 Trocar Insertion Technique 274 Grasping Instruments 275 Cutting Instruments 275 Energy Sources for Laparoscopic Surgery 275 Clips and Staplers 276 Suturing and Knot Tying 278 Glues, Bioadhesives and Hemostatic Agents 279 Aspiration and Irrigation Instruments 279 Instrumentation for Port Site Closure 280 Insufflant System 280 Visualization System 280 Operating Room Setup 281 Patient Positioning and Draping 282 Placement of Operative Team and Equipment 283 Conclusion 284 References 284 Introduction Laparoscopic surgery, reconstructive and ablative, is being increasingly applied in the treatment of a vari- ety of benign and malignant conditions affecting the urinary tract. Improvements in instrumentation and technology have played a pivotal role in the expanding applications of laparoscopic and minimally invasive surgery. This chapter will highlight the fundamental and practical aspects of laparoscopic instrumentation common to most laparoscopic urological procedures. Laparoscopic Instrumentation Instruments for Laparoscopic Access Transperitoneal Access Closed Access Using the Veress Needle. In the closed approach, a Veress needle (Fig. 1) is initially placed percutaneously into the peritoneal cavity, usually through one of the port sites [1]. The standard Veress needle is a metallic needle with a retractable protec- tive blunt tip. The blunt tip retracts when the tip of the Veress needle is pressed against a tough structure such as fascia, thus exposing the sharp edge of the needle. Once the needle passes through the layers of the abdominal wall and enters the peritoneal cavity, the blunt tip is deployed, thereby protecting the ab- dominal viscera from injury from the sharp tip. The cannula is hollow, allowing for initial peritoneal insuf- flation. The Veress needle is available as a disposable or a reusable instrument. Certain modified Veress needle- type devices are available. One such device is the 2-mm Minisite (USSC, Norwalk, CT) port, which is the author's instrument of preference for obtaining closed peritoneal access. The Minisite has a retractable tip similar to the Veress needle, and can also be used as a 2-mm cannula by removing the inner trocar nee- dle. In cases where the correct position of the needle is questionable, a 1.9/2.0-mm telescope can be passed through the Minisite cannula to assess its position. For pelvic laparoscopic procedures, the patient is usually supine and the Veress needle is placed through a subumbilical incision. The bladder is emptied and 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 12 Laparoscopic Instrumentation Monish Aron, Mihir M. Desai, Mauricio Rubinstein, Inderbir S. Gill
Laparoscopic Instrumentation
Mar 08, 2023
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