Aug. 13, 2024
Laparoscopic Hand Instruments, Accessories and Ergonomics
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READ ABOUT LAPAROSCOPIC EQUIPMENT AND INSTRUMENTS
Because of the complex modern technology, any things can go wrong. Equipment and instrumentation possess a much greater impact and importance in laparoscopic surgery. This is a proven fact that visualization and tactile exploration of the operative field is definitely only indirectly achieved through optical systems and instruments. The surgeon must be sufficiently acquainted with the equipment to make use of it, troubleshoot and solve the inherent problems.
IMAGING SYSTEM
Imaging system includes the Laparoscope, Light source, Light cable, Camera, and Monitor.
A. Laparoscopes: Laparoscopes are either rigid or fibre optics. Popular are rigid ones, like 0°, 30°, 3mm, 5mm, and 10mm. The 30° angled scopes can be rotated and can see down as well look up the anterior abdominal wall and side ways. The scope is attached with light cable and the distal tip is inspected for fibre bundle transmission. If the fibre damage is 25% or more then the scope must be replaced.
B. Source of light: The brand new source of light for example 250 watt halogen lamp continues to be supplied with a condenser system, But Xenon lamp gives better visual clarity. The light intensity can be regulated manually or automatically. High intensity Xenon lamp gives better visual and photographic clarity.
C. Light Cable: Light carrier is very important. It may either be a fluid or perhaps a glass fibre light cable. Within the cable, there shouldn't be sharp bends and cracks in the plastic sheath, if it's there, then your cable ought to be changed for good light transmission. The cable is available at different diameters and lengths. The diameter of the fibre bundle ought to always be chosen slightly larger then your lens system and should not be too long.
D. Cameras: Now high resolution, small , light weight cameras are available, which is easy to handle, they offer picture of optimal sharpness, high resolution and excellent colour reproduction. Just one chip camera has resolution of point 450-600; But the 3 chip cameras with increased then 750 horizontal lines give excellent visual clarity. Usually single chip camera is adequate for routine laparoscopic surgeries but when surgery is recorded for later inclusion in larger film or video production, three chip camera is preferable. Now a recent version of digital 3 chip camaras with integrated image processing modules can be obtained.
E. Monitors: The video monitor must generate high res image after the S-VHS connection. Larger video screen is preferred, 20 inches and above, non flickering medical monitors rich in resolutions more then camera is preferred.
Gas for pneumoperitonium
Air was the first gas used to produce pneumoperitoneum, but has largely been abandoned. The primary drawback to air may be the risk of air embolism.
Characteristics from the ideal insufflating agent
1. Co2: Co2 is an odorless, colorless gas. It's a easily available, stable, naturally formed within the tissues and subsequently eliminated by the lungs. Due to these functions, Co2 is easily the most commonly used gas for insufflation during laparoscopic procedure.
Advantages
Disadvantages:
Nitrogen is biologically inert, colorless, gaseous element that is found free in the air. Nitrous oxide has been suggested for that procedures performed under local anesthesia, or for patients with pulmonary disease undergoing longer procedures.
Advantages
Disadvantages
Helium is a colorless, odorless, tasteless gas that's from gas. This inert gas is neither combustible itself, nor supports combustion. Helium is less soluble in water than co2.
Advantage:
Disadvantages
4. Argon
Argon gas is colorless, odorless, noncombustible, and chemically nonreactive.
Advantage
Disadvantage
LAPROFLATTOR
The Electronic CO2 Laproflattor is really a general purpose insufflation unit to be used in laparoscopic operations. Controlled pressure insufflation of the peritoneal cavity can be used to achieve the necessary work area for laparoscopic surgery by distending the abdominal wall and depressing the hollow organs. Automatic insufflators allow the surgeon to preset the insufflating pressure also it supplies gas until the required intra-abdominal pressure is reached. The insufflator activates and delivers gas automatically when the intra-abdominal pressure falls due to gas escape or leakage from the ports. Insufflation pressure could be continuously varied from 0 to 30 mm Hg; total gas flow volumes can be set to any value in the range 0-9.9 liters/mm. Patient safety factors are ensured by optical and acoustic alarms in addition to several mutually independent safety circuits. The important indicators of insufflators are preset pressure, actual pressure, flow rate and total gas used.
Suction Irrigation Machine
It is employed for flushing the abdominal cavity and cleaning during endoscopic operative intrusions. It's been designed for use with the AR suction /instillation tube. Its electrically driven pressure/suction pump is protected against entry of bodily secretions. The suction irrigation machine can be used frequently during the time of laparoscopy to create the concept of vision clear. Most of the surgeons use normal saline or ringer lactate for irrigation purposes. Sometimes, heparinized saline can be used to dissolve blood clot to facilitate proper suction in the event of excessive intra-abdominal bleeding. Suction and Irrigation hand apparatus. Irrigation and suction are necessary during laparoscopic surgeries specially to maintain clear visual field and maintained hemostasis. It comes in 5mm and 10mm reusable sizes. The suction tip is extremely helpful for intermittent suction and as blunt dissecting instrument in place of finger, as we use within conventional surgeries.
Operative hand instruments
Reusable and disposable instruments are commercially accessible. Disposable instruments provide better performance and better safety on single use. To make it cost effective the surgeon has to reuse the disposable instruments after sterilisation. Reusable instruments are significantly cheaper in the long run, however, they require proper cleaning and maintenance.
Veress Needle
Veress needle was introduced by a chest physician for aspiration of pleural effusion keeping in mind that it is spring mechanism and blunt tip may prevent the injury of lung tissue. Veress needle includes an outer cannula with a beveled needle point for cutting through tissues ((blank) 8). Inside the cannula it comes with an inner stylet, which is packed with a spring. This spring springs forward in response towards the sudden decrease in pressure encountered upon crossing the abdominal wall and entering the peritoneal cavity. The lateral hole about this stylet enables CO2 gas to become delivered intra-abdominaly. Veress needle is used for creating initial pneumoperitoneum so the trocar can enter safely and also the distance of abdominal wall from the abdominal viscera should increase. Veress needle way is probably the most widely practiced way of access. It is crucial to check veress needle each time before using it, for its (1) potency and, (2) spring action. Veress needle will come in three lengths 80mm, 100mm and 120mm. In obese patient 120mm and in very thin patient with scaphoid abdomen 80mm veress needle ought to be used. Veress needle should be held like a dart at the time of insertion.
2. Hassan Cannula
It's less commonly used than veress. It usually cuts down on the risk of vascular and hollow visceral injury. It's an extremely safe instrument to go in the abdomen, particularly in a patient that has previously undergone intra-abdominal procedures. This cannula consists of three pieces: a cone-shaped sleeve, a metal or plastic sheath with a trumpet or flap valve, along with a blunt tipped obturator. About the sheath there are two struts for affixing two fascial sutures. These sutures are then wrapped tightly around the struts. Thereby firmly seating the cone shaped sleeve into the laparoscopic port. This creates a highly effective seal to maintain penumoperitoneum.
B. Trocars
The term &#;trocar&#; is usually used to refer to the whole assembly but actual trocar is a stylet that is introduced with the cannula. The trocars are available with different type of tips. The cutting tips of those trocars are generally in the shape of a 3 edged pyramid or a flat two edged blade. Conical tipped trocars are meant to be less traumatic towards the tissue. The tip can be penetrated through the parietal wall without cutting along with a decreased risk of herniation or haemorrhage is reported.
Cannulas have been in general produced from plastic or metal. Plastic devices whether they are transparent or opaque, need to be designed in such a way as to minimize the reflection of light from the telescope. Reusable and disposable trocars are constructed by a mixture of metal and plastic. The tip of disposable trocar includes a two edged blade. These are extremely effective at penetrating the abdominal wall by cutting the tissue as they pass through. Most of the disposable plastic trocar has a spring loaded mechanism that withdraws the sharp tip immediately after it passes through the abdominal wall to reduce the incidence of injury of viscera. Trocar and cannula are of various sizes and diameter depending upon the instrument that it is used. The diameter of cannula ranges from 3 mm to 30 mm; the most typical size is 5mm and 10 mm. Newer and more effective disposable trocar designs incorporate unique design features such as direct serial incision from the tissue under visual control.
All of the cannulas have a valve mechanism at the very top. Always inspect the trocar to ensure that all the valves move smoothly and, that the insufflation valve is closed (to prevent losing pneumoperitoneum). The valves of cannula provide internal air seals, which permit instruments to move in and out within cannula with no loss of pneumoperitoneum. These valves can be oblique, transverse, or perhaps in piston configuration. These valves can be manually or automatically retractable during instrument passage. Surgeon should remember that sharp trocars although looking dangerous are actually better than blunt ones, because they need less force to introduce inside the abdominal cavity and the likelihood of inadvertent forceful entry of full length of trocar is lesser. The finish from the cannula is either straight or oblique. An oblique tip is felt to facilitate the simple passage from the trocar through the abdominal wall.
C. Reducing Sleeve: It's used to reduce the size of the main harbour from 10mm to 5mm or 5mm to three mm, to ensure that pneumoperitoneum is maintained when ever surgeon changes the instrument from larger diameter to smaller diameter.
D. Needle holder: Laparoscopic needle holder can be obtained with a straight or curved tip. Two needle holders are essential to perform swift endo-suturing, although endo-suturing can be done satisfactorily with a single needle holder along with a grasper. In-line grip needle holders are ergonomically much better than pistol grip needle holder.
E. Port closure instrument: They are self innovative hand instruments to close the laparoscopic ports, especially 10mm or larger ports, as needed
Disposable or Reusable Instruments
Several factors should be considered during the time of choosing laparoscopic instrument, including cost, availability and reliability. Reusable instruments are costly initially but in long run they are economical. In developing countries, disposable instruments are very rarely used because labour price is low compare to the cost of disposable instrument. In Europe and USA, surgeons often choose to use disposable instrument to save high labour cost. The disposable instruments aren't sterilized properly by dipping in gluteraldehyde because they are not dismountable. Insulation of disposable instrument also can be torn easily be responsible for electrosurgical injuries.
Laparoscopic hand instruments vary in diameter from 1.8 to 12mm but majority of instruments are made to go through 5 to 10mm of cannula. The instruments will also be of various lengths (vary from company to company, usually varies from 18 to 45cm) but you are ergonomically convenient to use if they have same length of approximately 36 cm in adult and 28 cm in pediatric practice. Shorter instruments 18 to 25cm are adapted for cervical and pediatric surgery. Certain procedures for adult can also be performed with shorter instrument in which the space is constricted. Forty-five centimeter instruments are utilized in obese or very tall patients. For better ergonomics 1 / 2 of the instruments should be inside the abdomen and half outside. If half of the instrument is in and half out, it behaves like a class-1 lever; and it stabilizes the port nicely and thus surgery becomes convenient. Most of the laparoscopic procedures need a mixture of sharp and blunt dissection techniques, often utilizing the same instrument in a number of different ways. Many laparoscopic instruments can be found in both re-usable and disposable version. Most re-usable instruments are partially dismountable in order that it can be cleaned and washed properly. Some manufacturer have produced modular system where the main instrument could be changed to suit the surgeon favorite attachment like handle or working tip.
Most laparoscopic instruments like graspers and scissors have basic opening and closing function. Many instruments manufactured during past few years can rotate at All over angle which boosts the degree of freedom of these instruments.
Most of the hand instruments have three detachable parts.
a) Handle
b) Insulated outer tube
c) Insert which makes the end from the instrument.
Certain instrument handles are made to allow locking of the jaw. This is very useful when the tissue must be grasped firmly for long period of time preventing the surgeons hand from getting fatigued. The secure is usually incorporated into the handle so that surgeon can certainly lock or release the jaws. Scalping strategies will often have a ratchet so the jaws could be closed in various positions and to different pressures. The majority of the laparoscopic instrument handles have attachments for unipolar electrosurgical lead and many have rotator mechanism to rotate the tip of the instrument. Some multifunctional laparoscopic handles have attachment for suction and irrigation. The Cuschieri Ball Handle was introduced by Prof. Sir Alfred Cuschieri. This handle lies comfortably in surgeon&#;s palm. This design reduces the fatigue of surgeon and eases rotation of the instrument by getting rotation inside the palm instead of using wrist rotation. Squeezing the leading from the handle between your thumb and the first fingers increases the jaw closing force; squeezing the trunk from the handle between your thenar eminence of the thumb and last fingers opens the jaws. Cuschieri pencil handle also offers great ergonomic value specially when combined with needle holder. This handle allows the angle between your handle and the instrument to be altered to suit the surgeon&#;s wrist angle. The conveniently placed lever of the pencil handle when pressed can change the angle. Just like ball handle, pressure in front boosts the jaw closing force while pressure at the rear opens the jaw. Insert of hand instrument varies only at the tip. It may be grasper, scissors, or forceps. This grasper may have single action jaw or double action jaw. Single action jaw open under double action jaw but close with greater force thus, the majority of the needle holders are single action jaw. The necessary wider opening in double action jaw exists in grasper and dissecting forceps. Single action graspers and dissectors are utilized where more force is needed.
D. Different kind of Graspers
These graspers are good when you don&#;t have total control over depth and surgeon really wants to are employed in single plane in controlled manner particularly during adhesiolysis.
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E. Instruments for Sharp Dissection
Scissors are one of the oldest surgical instruments used by surgeons. Scissors are utilized to perform many tasks in open surgical treatment but its use in minimal access surgery is restricted. In minimal access surgery scissors require greater skill because in inexperienced hand you can get unnecessary bleeding and damage to important structures
Spatula, Hook and Harmonic Scalpel
Spatula has a flat tip for dissecting the gallbladder in the liver bed. It is much safer than the hook. Hook has a L shaped tip. Usually it is accustomed to dissect the gallbladder from the bed of the liver. Some surgeons also use this instrument for opening of the intestine. Now a days in modern laparoscopic surgery ultrasonic scalpel (Harmonic scalpel) can be obtained for advanced procedures. They are available as either disposable or reusable. Reusables are of of three sizes, large, medium large and medium. They are used to clip cystic artery and cystic duct based on their size. Disposable clip applier includes preloaded 20 clips per unit since the Protack (popular in mesh repair in hernia) is available in 30 per unit.
ERGONOMICS
Operative laparoscopy has changed the concept of surgery from prolonged painful recuperative periods with long scars of open surgery to short stay, painless, and cosmetically satisfying surgery. It's been achieved at the expense of surgeons&#; discomfort and fatigue, thus putting both surgeon and patient in danger. Inadequate understanding of ergonomics together with ergonomically deficient design of laparoscopic instruments has been cited as you possibly can causes. Increased technological complexity and sometimes poorly adapted equipment have resulted in increased complaints of surgeons&#; fatigue and discomfort during laparoscopic surgery.
Ergonomic Variable
The important variables that have been studied include hand size, handle to tip force transmission, optimum height from the surgeon&#;s hand and height of the operating table, view site with regards to monitor position and the technique of gripping the instruments.
Hand size
Hand size is an essential variable to consider when designing laparoscopic hand tools. This is because laparoscopic surgeons, especially women using glove sizes 6.5 or smaller, experience musculoskeletal problems while using the common laparoscopic instruments. Moreover, subjects who reported musculoskeletal problems performed a significantly greater percentage of laparoscopic cases and located the stapler and graspers difficult to use for any greater percentage of time than those not reporting problems.
Handle to tip force transmission
Data in the Society of yankee Gastrointestinal and Endoscopic Surgeons (SAGES) reveal that laparoscopic instruments are afflicted by ergonomically inadequate handle designs and inefficient handle to tip force transmission, which lead to surgeons&#; fatigue, discomfort, and hand paresthesias. Studies quantifying forearm and thumb muscle workload by processed electro-myogram (EMG) demonstrated that the peak and total muscle effort of forearm and thumb muscles were significantly greater when the grasping task was performed using the laparoscopic instrument. It was discovered to be more prevalent among junior laparoscopic surgeons having under 2 yrs of experience.
Optimum height
Discomfort and difficulty ratings were lowest when instrument handles were positioned at elbow height. The positioning of laparoscopic instrument handles needed to be near to surgeons&#; elbow level to minimize discomfort and upper arm and shoulder muscle work. It was found to match an approximate table height of 64 to 77 cm above floor level.
Technique of gripping
Palm grip hand position using the pistol handle (thumb away from ring with the palm resting about the thumb ring) is more efficient than the finger-in-ring grasp since it significantly reduces the muscle forces required for grasping having a laparoscopic instrument. Many surgeons do, in fact, use the palm grasping hand position for sustained grasping tasks during laparoscopic surgery. Moreover, use of finger tips rather than finger base during finger-in-ring grasp during tissue dissection reduces discomfort. Most of the surgeons performing regular laparoscopy are not aware the complications of nerve injury and neuropraxia following improper gripping technique. Experience in laparoscopic surgery does play a major effect on knowledge about ergonomical problems. Operating for prolonged hours with eyes focused on video monitors results in eye strains among laparoscopic surgeons. Placement and adjustment of monitors have little benefit in improving the situation though experience led to some improvement. Utilization of laparoscopy is associated with significant ergonomic problems, hence proper training and awareness among laparoscopic surgeons is essential in India. This is only possible if an authorized accreditation council sets up guidelines and oversees working out programs, thus making laparoscopy safer for both surgeons and patients.
Recommended Laparoscopic Instruments for Surgeons:
Recommended Laparoscopic Instruments for Gynecologists
READ ABOUT LAPAROSCOPIC EQUIPMENT AND INSTRUMENTS
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Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.
Core Tip: Check for pregnancy in women of the childbearing age group. Make an alternative advanced plan with the patient regarding unexpected intra-abdominal circumstances. Consider adequate thromboprophylaxis and antibiotic prophylaxis. Intraoperatively, surgeons should ensure correct patient positioning and placement of stack and monitor(s). Establishing pneumoperitoneum safely, proper use of energy devices/staplers, use of lowest possible intra-abdominal pressure, avoidance of 10-15 millimetre ports for placement of drains; and a thorough &#;time out&#; at the end are some of the other important intraoperative considerations. The operating count by nurses should include specimens and retrieval bags. Important postoperative considerations include analgesia, early ambulation, and careful attention to early warning scores.
Laparoscopic surgery could be regarded as one of the greatest advances in the field of surgery. It has brought with it a revolution in the use of digital and robotic technology in surgical practice. It has radically shortened the patient recovery times compared to the &#;open&#; operations. Even more remarkably, these gains have been made whilst simultaneously enhancing the quality of surgery[ 1 , 2 ]. Laparoscopic surgery is associated with less pain, fewer wound infections, reduced hospital stay, reduced morbidity and mortality and early return to work and improved overall quality of life[ 3 , 4 ]. However, when laparoscopy was first introduced there were concerns regarding its safety[ 5 , 6 ]. Fortunately, with time as surgical teams have progressed over their learning curves, many of the initially reported complications have become relatively infrequent[ 7 ].
The main drawbacks of laparoscopic surgery are reduced tactile and depth perception, which could be critical in many surgical procedures (e.g., segmental colectomy for small malignant polyps)[ 21 ]. Where feasible, we suggest endoscopic procedures for such lesions and, if surgery is required, preoperative endoscopic tattooing could help intraoperative identification of the pathology[ 22 , 23 ]. A preoperative review of radiological imaging with an experienced radiologist can also be helpful.
Over the last couple of decades, an increasing variety of operations are being performed laparoscopically[ 14 - 16 ]. In many cases, the laparoscopic approach has become the norm. For instance, it is difficult to believe that gastric bypass for obesity was once performed using an open approach. A similar expansion of laparoscopy is also being observed in emergency surgery in haemodynamically stable patients[ 17 , 18 ] Laparoscopy has also been reported to be safe with reduced risks of nontherapeutic laparotomy and mortality in patients with blunt abdominal trauma[ 19 ]. Though its role in penetrating abdominal trauma is less clear, some surgeons believe it may be useful as a screening tool for identifying patients who would require laparotomy[ 20 ]. Procedures can be laparoscopic (such as gastric bypass for morbid obesity), or hybrid-combined open and laparoscopy (such as anterior resection for rectal cancer) depending on the underlying pathology and experience of the surgeon.
Additionally, laparoscopic surgery may be challenging in a patient who has previously undergone an open abdominal operation especially an emergency laparotomy. In these patients, safe access to the peritoneal cavity may be difficult[ 8 ]. Surgeons should generally try to avoid areas where intra-abdominal adhesions are likely to be maximum for pneumoperitoneum and first port insertion. For example, authors would suggest optical pneumoperitoneum in left upper quadrant as the entry point in patients who have had a previous midline laparotomy.
Another potentially serious issue could be surgery without the knowledge that the patient is pregnant. Though this has implications for all pregnant women and the unborn baby, the implications are even more severe after operations such as bariatric and metabolic surgery[ 11 ]. All women in the childbearing age group should, therefore, be offered a routine urine pregnancy test at preassessment to rule out pregnancy[ 12 ].
Patient selection plays a key role in enhancing the safety of laparoscopic surgery[ 8 , 9 ]. In addition to the risks associated with a general anaesthetic, laparoscopy is associated with risks due to increased intra-abdominal pressure (IAP) and in some cases extreme patient positioning[ 10 ]. There is no absolute contraindication to laparoscopic surgery but patients with significant medical comorbidities should be treated with caution just like any other surgery. Some patients may be suitable for laparoscopic surgery but not the corresponding open procedure and this should be discussed with the patient in advance. The morbidity and mortality of the open surgery may be too high (such as frail patients or those suffering from severe obesity) and surgeons may need to either back out without performing any procedure (such as when faced with extensive adhesions or a cirrhotic liver or a huge liver) or perform a different procedure to the one planned (such as a subtotal cholecystectomy instead of a total cholecystectomy; or sleeve gastrectomy in place of Roux-en-Y gastric bypass). An advanced discussion with patients and their families regarding these aspects can help surgeons take the most appropriate course of action in such challenging circumstances.
A good and effective team brief is crucial before any operation. All members of the team including the consultant surgeon, surgical assistants/trainees, anaesthetist, anaesthetic trainee/operating department practitioners, scrub nurse, and circulating nurse should be present during the team brief. These sessions provide an opportunity for discussion of any anticipated difficulties, measures for prophylaxis of venous thromboembolism, antibiotic prophylaxis, glycaemic control, patient allergies, patient warming, patient positioning, location of the screen, need for X-ray, etc. We strongly recommend team briefings are done as part of the World Health Organisation (WHO) &#;safe-surgery&#; checklist, which has been shown to reduce human error and adverse effects while improving communication and teamwork[11,24]. While discussing allergies, particular attention should be paid to allergies to something that would normally be used during or after surgery. Some elective procedures may need to be deferred while patient is referred to appropriate specialists for further testing and confirmation of allergies.
Proper patient position is essential for the safe performance of laparoscopic surgery. Appropriate precautions must be taken to ensure neutral positioning of major joints and padding of pressure points[25,26]. Some surgeons prefer a "French" position (surgeon stands between the legs of the patient) whereas others prefer standing on the right side of the patient. Regardless of these preferences, basic principles of positioning remain the same. The patient must be secured with a strap over the chest/thighs with or without footrests (depending on whether reverse Trendelenburg position is anticipated during the surgery) to avoid lateral and caudal slippage[11]. Likewise, for pelvic surgery, the patient may need to be in Trendelenburg position. In these cases, hips and knees should be kept in a neutral position in secured leg supports with soft cushions for all pressure points. Shoulder supports can also help prevent cephalad sliding of patients. If stationary retractors are required, such as Nathanson's liver retractor, they should be fastened securely to the operating table to minimise intra-operative adverse events, such as liver injuries[27]. One should use utmost care while introducing and removing these retractors. The liver may be densely adherent to underlying vascular structures and careless lifting may lead to traction injuries. Moving the patient on and off the operating table should be carried out properly to avoid patient and staff injuries especially for patients with obesity where air mattresses (such as HoverMatt®, HoverTech International, Allentown, PA, United States) may be useful[28].
A significant number of laparoscopic surgeons suffer from work-related musculoskeletal injuries (up to 70%)[29], and as such ergonomics are more pertinent to laparoscopic surgery than probably open or even robotic surgery. The patient's position, height of the operating table, port position, and laparoscopic monitor setup are some of the important factors to consider in this regard[30,31]. One key suggestion is that the surgeon, the operating field, and the monitor should be in a straight line with triangulation between the camera and main operating ports. The height of the monitor should be just below the surgeon's eye level (preferably 0 to 150) to avoid sprain due to prolonged neck extension[32,33]. Fatigue amongst the surgeon and assistant may increase the risk of error during the procedure, and hence every effort should be made to improve ergonomics. To overcome some of these ergonomic challenges, modern laparoscopic theatre suites are equipped with permanently installed ceiling suspended multiple flat-screen monitors with adjustable inclination[34]. Relative lack of depth perception (2D view) has been a major disadvantage with laparoscopy compared to open surgery. To overcome this, 4K ultra high definition technology[35] and 3D laparoscopic technology have been introduced[36], and several trials have compared the two[35,37]. Neither seems superior to the other, and a recent consensus statement from the European Association of Endoscopic Surgeons concluded that further robust research is required to investigate the avantages of 3D laparoscopy system[38]. Higher cost as well as the stress of the 3D laparoscopy system and issues with surgeon&#;s vision mean that these systems are not yet in widespread usage[39].
It has been suggested that up to 50% of major complications in laparoscopic surgery occur at the time of port insertion[4]. Surgeons should, therefore, be proficient with different techniques for establishing pneumoperitoneum. Open Hasson technique[40], closed Veress needle entry (named after Janos Veres)[41] and optical ports (with or without prior pneumoperitoneum using a Veress needle) are the most common methods currently used. A recent Cochrane review showed none of these approaches stand out in terms of complications such as visceral injuries and major vascular injuries[42]. However, open Hasson&#;s method is associated with the least chance of entry failures compared to the other two modalities[42]. Even though many surgeons have a preferred technique, the selection of entry technique should probably be based on patient characteristics. For example, the open juxta-umbilical approach is safe and quick for thin to averagely built patients with less abdominal wall fat and with no previous midline laparotomy; whereas optical port insertion in left upper quadrant (with or without prior Veress needle pneumoperitoneum) might be safer for patients with previous midline laparotomy or obesity[43]. In any closed technique, the first port should always be introduced using optical guidance and left upper abdomen (Palmer&#;s point) is regarded to the safest place for this purpose by many surgeons[44].
The size of the primary port (10-12 mm or 5 mm) also depends on the surgeon's preference and type of surgery. For example, some surgeons prefer a 5 mm primary port for paediatric patients to minimise tissue trauma. However, the quality of the picture obtained through a 5 mm scope can be inferior to a standard 10 mm scope due to fewer optical fibres. The size and position of subsequent ports depend on the operation and anticipated instruments in use. Most of the instruments can be safely used through 5 mm ports, but staplers, large clip applicators, retrieval graspers usually require 12 mm ports. Surgeons should also bear in mind that a curved needle will not go through a 5 mm port whereas a ski-shaped needle will. Curved needles can be lost intra-abdominally in an attempt to retrieve them through a 5 mm port[11]. Surgeons should always follow any needle during insertion and removal from the abdominal cavity. Occasionally, larger 15 mm ports are required for thick stapler devices as well as to extract large specimens. However, in the authors' experience, this is rare as most specimens can be removed through a 12 mm port site with some stretch. However, if a 15 mm port is used, the port site should always be closed irrespective of the patient's body mass index. All subsequent port placements, after the primary port insertion, should be under direct vision to avoid injury to the underlying viscera. Injury to inferior epigastric vessels is reported to be the commonest cause of port site bleeding[45,46]. In thin patients, transillumination can help reduce the chance of inadvertently injuring these vessels.
There are two types of trocars: Bladed and non-bladed that are available for subsequent port placements. The data on comparing the two types are very limited, but non-bladed trocars are probably associated with less trocar-site bleeding with no difference in visceral injury[47]. It is our view that surgeons should only use blunt-tipped non-bladed trocars in laparoscopic surgery as they are less likely to result in inadvertent injuries to epigastric vessels and viscera. All ports should be placed according to the triangulation principle for the better ergonomics[48]. After all the ports are inserted, a gross inspection of the peritoneal cavity is important to identify any inadvertent injury or any unexpected finding. Standard laparoscopic ports are 100 mm in length and suitable for most regular laparoscopic procedures. However, extra-length (150 mm) ports may be necessary to gain access to patients with thick abdominal walls. Usage of appropriate length ports helps to prevent repeated port displacement and fascial injury caused by repeated insertions. If available, balloon tip ports can prevent port displacement.
Optimal pneumoperitoneum is vital for safe laparoscopic surgery to ensure adequate visualisation. But, it can also have adverse effects especially on the cardiovascular system[49-51]. Good communication with the anaesthetist is important at the start of insufflation. The rate of insufflation and intra-peritoneal pressure are the key considerations for each procedure[52]. A rapid rise in IAP rise could result in hemodynamic instability from bradycardia or other life-threatening cardiac arrhythmias especially in elderly patients and those with pre-existing cardiac disease[49,50,53,54]. An initial slow rate of insufflation especially at the beginning of the procedure could minimise such events. IAP > 12 mmHg is considered intra-abdominal hypertension with adverse effects on the cardio-respiratory system mainly due to diaphragmatic splinting and carbon dioxide-induced hypercarbia[52].
As a general rule, the lowest possible IAP should be maintained, and an IAP > 15 mmHg is very rarely required. Additionally, good abdominal wall relaxation could improve surgical view[50]. The patient's position could further exaggerate these adverse effects of pneumoperitoneum. For example, in the Trendelenburg position, pressure of viscera on the diaphragm can lead to a reduction in the functional residual capacity[50,51].
The camera is the eye of the surgeon! Compared to old low-resolution scopes, modern laparoscopes provide high-resolution images enabling the smooth performance of complex and delicate procedures[55,56]. The assistant holding the camera is responsible for providing a clear, focused image to the surgeon. It is important that the assistant knows operative steps and ideally also, the manoeuvres unique to each surgeon. Appropriate training and experience are key to this[57]. The camera is located at the tip of the scope with a fixed angle ranging from 0° to 70°[53], and some with flexible tip allow complete 0 to 180° visualization (LTF-V2 Deflectable Tip Laparoscope, Olympus America Inc., Melville, New York). The familiarity of these angles is important for assistants. Additionally, the camera holder must try to keep the surgical field in the centre of the screen with minimal turbulence.
Sharp instruments such as a diathermy hook and scissors should be followed with the camera during insertion and withdrawal to avoid any inadvertent injuries to the viscera. Before usage, white balancing should be done to achieve a digital image with true colours. White surfaces, such as clean swabs reflect the light enhancing the image, while dark surfaces such as blood, absorb the light and compromise the view. Therefore, the assistant must try to avoid blood-stained and reflective surfaces. The surgeon at the same time should attempt to keep the surgical field tidy. Fogging is a common problem in laparoscopy especially at the beginning of the procedure due to the temperature difference between cold scope and warm peritoneal cavity. Pre-warming with warm water[58-60] or liquid scope warmer (WarmORTM, The O.R. Company, Antioh, TN, United States), anti-fog solutions (FREDTM, United States Surgical, North Haven, CT) are some of the options available for preventing fog formation.
The high intensity of the light can generate significant heat at the tip of the laparoscope. This can burn the drapes and even skin of the patient if due care is not taken.
Correct selection and proper usage of laparoscopic instruments are vital for safe performance of laparoscopic surgery. Describing all laparoscopic instruments is out of the scope of this article. However, we would like to highlight some of the key aspects of commonly used instruments. Tissue graspers, laparoscopic scissors, clip applicators, needle holders, staplers, and suction devices are some of the commonly used instruments in laparoscopic practice. Choice of the instrument depends on multiple factors such as nature of the tissue (delicate vs tough), characteristics of the instrument (traumatic vs non-traumatic), expected function (dissection vs retraction). For example, tissue graspers can be traumatic or non-traumatic depending on the surface characteristics of the jaw blades of the force used by the surgeon. Maryland's forceps are a traumatic device, which should not be used to handle delicate structures such as the small or large intestine. Instead, Johan&#;s non-traumatic forceps should be used for the bowel. It is worth bearing in mind that even atraumatic graspers can lead to tissue trauma if not handled gently. Similarly, Maryland's forceps are useful for blunt dissection and hold tissues (such as bleeding vessels) with their pointed tips. Sharp instruments such as laparoscopic scissors and diathermy hook should always be used under direct vision. Articulated instruments offer &#;robot-like dexterity&#; with an improved degree of freedom at lower cost[61,62]
Laparoscopic staplers of appropriate length and staple height should be used depending on the tissue[63-65]. Although modern tri-staplers are shown to be safe and robust, utmost care should be exercised with attention to detail[66,67]. The surgeon needs to be familiar with the type of stapler they are using, and also have good working knowledge of different type of cartridges. Before firing a stapler in Upper Gastro-Intestinal (UGI) surgery, a routine check and communication with the anaesthetist are mandatory to avoid inadvertently catching the orogastric tube or temperature probe, or nasogastric tube within the stapler. All of these have has been reported as never events[68]. Routine use of nasogastric tubes and temperature probes should be avoided, especially in UGI surgery.
Powered staplers and flexible stapler devices (ECHELON FLEXTM, Johnson and Johnson, United States) have also shown some promising results in laparoscopic surgery[69,70]. For most operative procedures (including most bariatric surgery) standard length instruments are adequate. However extra-long instruments may be needed in some patients with severe obesity[71]. Surgical procedures requiring access to gastro-oesophageal junction such as hiatal hernia repair or bariatric surgery require a liver retractor. Different types are available and can be used based on the surgeon's preference and availability (Nathanson Liver Retraction System, Cook® Medical, United States and PretzelFlex Surgical Retraction System, Surgical Innovations, United Kingdom). However, utmost care is required to avoid tissue injury especially to the liver[27,72,73]. Laparoscopic ultrasound, yet another useful tool especially in hepatopancreatic and biliary operations can be helpful to localise lesions and reduced the incidence of complications[74-76]. More recently, use of Indocynanine Green for fluorescence-guided laparoscopic surgery has shown some initial promising results in hepatobiliary surgery, colorectal surgery, and surgical oncology. It can be useful in tumour localisation, lymph node mapping, and intra-operative angiography as well as cholangiography[77-79]. However, the protocols and technique need to be standardised and validated with further research.
Modern energy devices have facilitated the progress and development of laparoscopic surgery. Monopolar diathermy is the most basic energy device used in current practice utilised commonly for tissue dissection and haemostasis through hook or Maryland&#;s forceps. Compared to other devices, monopolar diathermy is known to cause significant lateral thermal spread, which requires cautious application close to delicate structures such as the bowel[80,81]. Additionally, inadvertent injuries due to cracked insulation, capacitance coupling due to the usage of metal or hybrid ports are other complications associated with monopolar diathermy[82-84]. Regular inspection and usage of plastic ports are effective means of preventing these potentially disastrous complications. The authors recommend avoiding metal ports for this reason. Surgeons or other team members can also accidentally step on the cutting pedal during the procedure as pedals are on the floor and often hidden under the drapes. We recommend reducing the default cutting setting down to zero as it is rarely needed during routine laparoscopic surgery.
Bipolar diathermy is often a safe alternative when monopolar diathermy is risky e.g. close to delicate tissues due to minimal lateral thermal spread or is contraindicated e.g. patients with cardiac pacemakers[74]. Several advanced energy devices are available and utilise different technology[80,85]. LigasureTM (Medtronic Technologies, Dublin, Ireland) uses bipolar energy with pressure to seal blood vessels up to 7 mm. HarmonicTM (Ethicon technologies, Raritan, NJ, United States), and SonoSurgTM (Olympus Technologies, Tokyo, Japan), use high-frequency ultrasonic waves to generate heat, thereby causing tissue coagulation and dissection with significantly lower lateral thermal spread compared to monopolar devices[80]. These devices can be safely used even in patients with cardiac pacemakers, in whom monopolar diathermy is contraindicated[86]. During usage, the active blade of these devices should be kept under direct vision to prevent any inadvertent injury to underlying tissues. Studies demonstrate heat at the tip of the device can lead to temperatures as high as > 100 °C and can last up to 20 s after usage[87]. Therefore, tip contact with vulnerable tissues should be avoided immediately after usage and surgeons should allow some time for it to cool down before using again. ThunderbeatTM (Olympus Technologies, Tokyo, Japan) is another device that combines both high-frequency ultrasonic waves and bipolar diathermy, which allows tissue dissection as well as sealing of vessels up to 7 mm[88]. Energy devices related burns may not be immediately apparent and result in late perforations with disastrous consequences[89,90].
Tissue dissection in laparoscopy can be a challenging task even for experienced surgeons due to a relative lack of haptic feedback. Laparoscopic scissors are often used for sharp dissection, whilst advanced energy devices could be used where tissues are expected to bleed. Pointed tip devices such as Maryland&#;s forceps are useful to open-up the tissue planes. Suction devices or laparoscopic pledgets can also be used to create tissue planes[91].
Any discrete bleeding vessel should be identified, isolated, and properly controlled before proceeding to the next step of the procedure. Diathermy is the most frequently used modality for haemostasis and is advocated for a capillary-sized vessel. Laparoscopic clips or Hem-o-lok® (Teleflex®, Morrisville, NC, United States) ligating clips are indicated for defined, named vessels. For larger vessels such as a splenic artery or ileocolic pedicle, we suggest using either locking clips e.g., Hem-o-lok® (Teleflex®, Morrisville, NC, United States) or vascular staplers (1.0 mm to 2.0 mm Endo GIATM, Medtronic, Minneapolis, United States, and Ethicon, Johnson & Johnson Medical, Belgium).
Bleeding from raw or inflamed tissue e.g., liver bed after a difficult cholecystectomy or pelvis during rectal resection can be difficult to control[91-93]. These can sometimes be controlled with topical haemostatic agents such as gelatins, collagens, thrombin, and fibrin sealants (BioGlue®, Cryolife Inc., Kennesaw, GA, United States), and synthetic glues[94,95]. Some of these agents e.g., Surgicel (Ethicon, Johnson & Johnson Medical, Belgium) can cause an intense inflammatory reaction, and lead to the formation of an abscess[96-99]. Occasionally, ligating or transfixing the pedicle with sutures provides the most secure control. We believe all laparoscopic surgeons should be able to carry out laparoscopic suturing. All energy devices can cause injury to nearby structures due to lateral thermal spread and as such, it is vital to keep the instrument completely under vision during use[80,85]. Once metal clips are applied, further diathermy should be avoided as it causes shrinkage of tissues underneath with subsequent loosening and slippage of the clip, and the metal clip could lead to the spread of the diathermy current to adjacent tissue causing thermal injury[82,83,100].
Laparoscopic suturing is an essential skill for all laparoscopic surgeons. Selection of correct needle size, length of the suture, proper handling of the needle at various angles are vital considerations for safe laparoscopic suturing. Additionally, pre-prepared laparoscopic knots with loops (ENDOLOOP®, Johnson & Johnson Medical, Belgium) are commercially available as a quick option for certain procedures as laparoscopic appendicectomy. Specific anchoring devices (such as ProTackTM, Medtronic Ltd., United Kingdom, and Securestrap®, Johnson and Johnson Medical, Belgium) can be used for mesh fixation during a laparoscopic hernia repair. However, they can be associated with complications such as chronic pain or erosions[101,102]. More recently, absorbable tackers have been introduced in an attempt to reduce the odds of these complications (AbsorbaTackTM, Medtronic Ltd., United Kingdom).
Laparoscopic surgery can be physically and mentally demanding for the surgeon and could easily lead to fatigue and errors[103,104]. We recommend short breaks during long or difficult procedures for the whole team. If the operation is not progressing as expected, a second opinion from and experienced colleague could be invaluable[105]. Surgeons should not regard conversion as a failure.
Towards the end of the procedure, surgeons should ensure adequate haemostasis and check for any inadvertent bowel injury. We also recommend ensuring adequate blood pressure and reducing the pressure while checking for haemostasis. A haemostasis check with low blood pressure and high-pressure pneumoperitoneum may be falsely reassuring.
Surgeons should consider closing all internal defects and 15 mm port sites. Most 10-12 mm port sites should also be closed except in patients with severe obesity where many surgeons do not recommend closing blunt 10-12mm port sites especially when ports have been angled during placement[106,107]. After the withdrawal of ports, all port sites should be checked for bleeding and adequate haemostasis must be ensured. Surgeons should finally check the operating count with nurses and do a proper "time out" to ensure all planned procedures have been performed. The operating count should include surgical specimens and specimen retrieval bags as it is not uncommon during laparoscopic surgery for surgeons to leave a specimen/retrieval bag intraabdominally during the surgery for later removal[11]. At the end of the procedure, we recommend a mental pause for the surgeon to reflect on the procedure &#; especially consider if all planned procedures have been performed; all foreign bodies such as tonsil swabs, retrieval bags, removed previously placed foreign bodies such as gastric bands, and specimens have been removed; and all ports that needed closing have been closed.
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