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Laparoscopic Instruments

Laparoscopic Instruments. Dr Deepak Dubey, Manipal Hospital, Bangalore. Light Source. Consists of Lamp Heat Filter Condensing lens Manual or automatic intensity control circuit. LAMPS Quartz Halogen- Electrodes of Tungsten Incandescent Bulbs Xenon. Laparoflator.

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Laparoscopic Instruments

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  1. Laparoscopic Instruments Dr Deepak Dubey, Manipal Hospital, Bangalore

  2. Light Source • Consists of • Lamp • Heat Filter • Condensing lens • Manual or automatic intensity control circuit • LAMPS • Quartz Halogen- Electrodes of Tungsten • Incandescent Bulbs • Xenon

  3. Laparoflator

  4. Light Cable (Fiber optic)

  5. Laparoscopic Instruments • Discovered by a Hungarian Internist Janos Veress in 1932 for collapsing infected lung in TB patients

  6. Port Closure needle (Carter –Thomason) needle

  7. Laparoscopic Bull Dog Clamps

  8. Laparoscopic Satinsky Clamp

  9. Hemolok (Weck) Clips

  10. Harmonic Scalpel

  11. Enseal

  12. Coagulation and Cutting devices in Laparoscopic Urology

  13. BJU 2005 • Overall score 41%. • Monopolar energy is the most preferred in 74%. • Monopolar energy is used by >85% for laparoscopic procedures. • Emergency Care Research Institute (ECRI): the rapid increase of laparoscopy has created simultaneous increase in injuries from ESI.

  14. Standard Techniques • Electrosurgical- Monoploar • Electrosurgical- Bipolar • Ultracision- Harmonic scalpel • Vessel sealing system- Ligasure Newer Technology • Gyrus-ACMI plasmakinetictrisector • Enseal- nanotechnology • Starion sealing system.

  15. Monopolarcautery. • Monopolar Electrosurgical • Coagulates vessels upto 2 mm • Current leaks, insulation breaks. • Capacitative coupling. • Contact with other conducting instruments • Thermal spread to vital structures • Charring of tissue • smoke

  16. Conventional Bipolar Cautery • Coagulates vessels upto 7 mm • Stray Energy • Blackening of Tissue • Insulation Failure

  17. The Harmonic Scalpel Mechanical energy Electrical energy

  18. The Harmonic Scalpel Blade extender Silicon nodes Protein coagulation Blade vibrates at 55,000/sec 50o C 100o C Proteins Disorganise to form a coagulum

  19. Harmonic Scalpel : Tissue effects Amaral JF, Chrostek CA .SAGES, 1995

  20. Harmonic Vs Electrocautery

  21. The Harmonic Scalpel: Technique • Tissue tension • Blade sharpness • Time • Power level • Grip force

  22. The Harmonic Scalpel: Technique

  23. The Harmonic Scalpel: Technique

  24. The Harmonic Scalpel: Technique

  25. Bipolar: Ligasure

  26. Conventional bipolar vs. modern technique • feedback-controlled bipolar vessel sealing • high current, low voltage • pulsating energy • ”cooling intervals” • simultaneous compression applied • instruments measure the current between jaws during coagulation • minimal thermal spread • sealing effect • denaturation of collagen and elastin fibers • no thrombus formation

  27. Collagen-elastin seal: Kennedy JS: Surg Endosc 1998

  28. Bipolar: Ligasure • Permanently fuses vessels upto and including 7 mm in diameter • Unique combination of pressure and energy to create vessel fusion. • Feedback-controlled system automatically discontinues energy when seal cycle is complete.

  29. Kennedy JS: Surg Endosc 1998

  30. Mean burst pressure(mmHg) by device Harold KL et al., Surg Endosc 2003

  31. FDA approval • ultrasonic energy for vessels up to 3 mm • EBVS (elctrothermal bipolar vessel sealer) for vessels up to 7 mm

  32. Extent of thermal injury by device • EBSV (Ligasure) • 2-3 mm • Ultrasonic scalpel (Harmonic) • 0-1 mm Landman J et al., J Urol, 2003

  33. Bipolar: GyrusPlasmakinetic system • Plasmacision leverages the electrically conductive properties of tissue fluid to form a tightly defined low-temperature plasma field. • In Plasmacision cut phase, the plasma corona precisely divides tissue. • In bipolar coag phase the Plasma knife tip delivers controlled RF to elevate tissue temeperature, dessicating and sealing blod vessels.

  34. Bipolar: Enseal • Utilises a nanotechnology feedback system wherein the temperature is adjusted by feedback from the nanoparticles in the device. • Minimises lateral thermal spread.

  35. Ligasure Vs Gyrus PK (Bursting pressure) Carbonnel 2003, J Laparoendosc Adv Surg Tech A;16(6):377

  36. Mean time to SEAL Comparison of devices to seal 5 mm bovine arteries Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.

  37. Mean Burst Pressure Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.

  38. Mean smoke/vapor production Lamberton 2008, J Endourol;16(6):377. Prospective comparison of four vessel sealing devices.

  39. Mean Tmax at 2 mm laterally

  40. All four instruments efficacious and safe in sealing and cutting blood vessels • All instruments created good seals with supraphysiologic bursting pressures • Enseal highest bursting pressure, however even lowest bursting pressures were in supraphysiologic range • Ligasure instruments create a wider seal • Heating higher with Harmonic ACE Ligasure Harmonic ACE ENSEAL Gyrus PK

  41. Its the Magician not the Wand who creates the Magic!!

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