� 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

Literature

1. Mettler,L.,M.Ibrahim,andW.Jonat,Oneyearofexperienceworkingwith

theaidofaroboticassistant(thevoice-controlledopticholderAESOP)in

gynaecologicalendoscopicsurgery.HumReprod,1998.13(1O):p.

2748-50.

2. Semm,K.,OperationslehrefürendoskopischeAbdominal-Chirurgie.1984,

Stuttgart,NewYork:Schattauer.

3. Veress,J.,NeuesInstrumentzurAusführungvonBrustoder

BauchpunktionenundPneumothoraxbehandlung.DtschMedWschr,1938.

41:p.1480.

4. Semm,K.,DiemoderneEndoskopieinderFrauenheilkunde.Frauenarzt,

1972.13(300-307).

5. Hopkins,H.H.,Onthediffractiontheoryofopticalimages.ProcRoySocA,

1953.217:p.408-415.

6. Brill,A.I.,Energysystemsforoperativelaparoscopy.JAmAssocGynecol

Laparosc,1998.5(4):p.333-45;quiz347-9.

7. Daniell,J.F.,Tailoringthelaserforinfertilitysurgery.ContempOB/GYN

Specialissue,1987(33-143).

8. Wallwiener,D.,etal.,[Thevalueoflaparoscopicandlaser-assisted

techniquesinreconstructionofdistalfallopiantubepathology].Zentralbl

Gynakol,1996.118(2):p.66-72.

9. Schemmel,M.,etal.,ComparisonoftheultrasonicscalpeltoCO2laserand

electrosurgeryintermsoftissueinjuryandadhesionformationinarabbit

model.FertilSteril,1997.67(2):p.382-6.

10. AdvinculaAP,WangK.Evolvingroleandcurrentstateofroboticsin

minimallyinvasivegynecologicsurgery.JMinimInvasiveGynecol.

2009;16(3):291-301.

11. MettlerL,SchollmeyerT,BoggessJ,etal.Roboticassistancein

gynecologicaloncology.CurrOpinOncol.2008;20(5):581-9.

� 49

12. NezhatC,NezhatFandNezhatC.Nezhat'sVideo-assistedandrobotic-

assistedlaparoscopyandhysteroscopy.4thEdition.CambridgeUniversity

Press,Cambridge,UK;availablefromMarch2013