Laparoscopic procedures require surgical skills that include dexterity, efficiency, and the ability to operate in a three-dimensional environment that is usually visualized in two dimensions. In addition to patient and surgeon positioning, one must be cognizant of equipment positioning in order to facilitate the expeditious progression of the operation. The equipment that is required to carry out a laparoscopic case, such as the components of the imaging system or insufflator, is oftentimes located on a laparoscopic tower (Fig.
). For the remainder of this section, basic laparoscopic equipment and the fundamentals of proper use will be discussed. A more detailed overview of instruments used in laparoscopic surgery can be found in the appendix of this book.
Laparoscopic tower that includes the necessary hardware during a laparoscopic case. (
a) Broad overview of components located on the tower. ( b) Insufflator measures the pressure and the flow of gas that is provided during the case. The surgeon can vary the insufflation pressure by adjusting the preset pressure. ( c) Transmitter that allows for signal to be sent to other monitors in the room. ( d) Camera connection. ( e) Light source connection Imaging System
The imaging system consists of the laparoscope, camera, video monitor(s), and light source. In general, the sterile components of this system include the laparoscope, camera, and fiber-optic cord that connects the laparoscope to the light source.
Most modern laparoscopes utilize a rod-lens system that was initially discovered by Harold H. Hopkins in the late 1950s. This was coupled with fiber-optic transmission technology by Karl Storz in the 1960s. Since then, the rod-lens system has revolutionized laparoscopy [
]. Significant advances have been made that allow for a number of laparoscope options, and therefore, not surprisingly, laparoscope selection is largely surgeon dependent. The ultimate goal when selecting a laparoscope is to maintain adequate visualization of the operative field. Laparoscopes can vary in a number of ways, as described below.
Size—The diameter (or size) of the laparoscope can vary from 0.88 mm to 12 mm. The larger the diameter of the laparoscope, the better the visualization. The most commonly utilized laparoscopes are 5 mm and 10 mm.
Angle—The angle of laparoscope can vary from 0 to 70°. A laparoscope that is 0° allows for a panoramic view, i.e., provides a view of the field that is directly ahead. In contrast, an angled laparoscope allows one to view a structure from different viewpoints without the necessity to change between ports. The most commonly utilized angles are 30° and 45°. An important tip to remember when using an angled laparoscope is to point the angle
away and not toward the area of interest [ ]. 7
Significant advances in camera designs have occurred as laparoscopy has become more popular. Perhaps the most notable advance in enhanced imaging in laparoscopy has been the introduction of the charged-coupled device (CCD) chip camera and digital video imaging (i.e., high-definition imaging). In the future, improvements in three-dimensional imaging will address depth perception, which is lost with two-dimensional imaging. There are a number of features and controls that one must be familiar when it comes to the laparoscopic camera. Controls present on the camera are manufacturer specific but, in general, include:
White balance allows for the color that is produced by the camera to be adjusted to the color of the light source. It is important to white balance the camera against a white object, such as a lap sponge, prior to use.
Focus allows for a clear image to be viewed. Prior to inserting the camera into the abdominal cavity, the camera is held 5 cm away from a target object, and the camera is focused to the clearest image.
Illumination adjustments allow for the intensity of the light to be increased or decreased.
Optical zoom allows for closer viewing of the operative field without loss of resolution of the image.
Monitors come in a variety of sizes and resolutions. Using a high-resolution monitor with a camera with similar capabilities optimizes the quality of the image.
The light source can vary by type and voltage. The current industry standard is a Xenon lamp with an output of 300 W. The laparoscope is connected to the light source through a fiber-optic cable. Any breakage in the fiber-optic cable results in decreased light transfer from the light source to the laparoscope, which results in decreased light being transferred to the operative field. Always be mindful of the fiber-optic cable once the illumination is turned on, regardless of whether or not it is connected to the laparoscope. It generates a significant amount of heat that has been known to start fires or burn holes through the sterile drapes and can lead to patient injury.
Other necessary equipment for laparoscopic surgery includes:
Insufflator—The insufflator is necessary to obtain pneumoperitoneum that allows for a successful laparoscopic case to be carried out. Several options are available for the type of gas used to insufflate, the most common being carbon dioxide. Carbon dioxide is preferentially used since it is nonflammable, colorless, and odorless. And, in general, it is safely absorbed and excreted. Insufflator tubing connects the insufflator to the instrument (i.e., trocar or Veress needle) that will facilitate the delivery of the gas into the abdominal cavity.
Trocars or ports are used to pierce the abdominal wall and serve as a conduit that allows for the entry of laparoscopic instruments into the abdominal cavity. They can vary in size and be either cutting or blunt. Trocars can have additional features, such as a side port, which allows for pneumoperitoneum to be maintained if the insufflator tubing is changed between ports [
]. 7 Instrumentation for Obtaining Access to the Abdominal Cavity
When initially planning the location for initial access for an abdominal laparoscopic procedure , first, survey the abdomen for scars from prior surgery or for any masses. Second, keep the planned operation and the operative field in mind. The most common site for initial entry and trocar placement is the umbilicus. The amount of soft tissue between the skin and the fascia is less compared to other areas in the abdomen in this location. It is also possible to hide a scar in an existing skin crease for improved cosmesis. Another common entry location is in the left upper quadrant in a location known as Palmer’s point, which is located 3 cm below the left subcostal border in the midclavicular line [
]. Instruments commonly used to obtain access for laparoscopic surgery will be briefly described next. For more specific details, refer to Chap. 8 — 14 Fundamentals of Laparoscopic Surgery.
First described by Dr. Harrith M. Hasson in the 1970s, the open technique for laparoscopic access is preferred by some as it is believed to minimize complications such as gas embolism, major vessel or visceral injury, or insufflation of the preperitoneal space [
]. The cannula itself is usually fitted with a cone-shaped sleeve and an outer secondary sleeve that allows for stay sutures to be placed to secure the port. It is primed with a blunt obturator to prevent injury to underlying structures. The Hasson cannula is inserted into the abdomen with the blunt obturator in place, and stay sutures secure the cannula to the fascia on either side to seal the opening in the abdominal wall and to prevent gas leak during the procedure [ 9 ]. 10
The Veress is used to obtain access to the abdominal cavity during laparoscopic surgery with the closed technique. The Veress needle was first discovered in the 1930s by Janos Veres, and it was Raoul Palmer who introduced the use of the Veress needle in laparoscopic surgery to establish pneumoperitoneum in the 1940s [
, 8 ]. It is a spring-loaded needle that is 12–15 cm long with an external diameter of 2 mm. It consists of a two-cannula system. The outer cannula has a beveled needle that is sharp to cut through the abdominal wall. The inner cannula is nested within the outer cannula and has a spring-loaded stylet with a dull tip. When the Veress needle is passed through tissue, direct pressure on the tip of the needle pushes the dull stylet into the outer cannula. Once the needle tip enters a space, such as the peritoneal cavity, the dull inner stylet springs forward and protects any underlying tissue. 11
Optical trocars are a relatively new technique that utilizes the conventional trocar and cannula push-through design. These units are designed in such a way that the trocar is hollow and allows for a 0° laparoscope to be inserted and locked along with the trocar. It can then be used to visualize entry into the abdominal cavity as the trocar pierces sequential abdominal wall layers. This system is generally used after the abdominal cavity has been insufflated [
, 10 ]. 12 Tips for “Driving” the Camera During Laparoscopic Surgery
All of the components of the imaging system are put together to allow the visualization of an image. Once access to the abdominal cavity is obtained, proper use of the imaging equipment to provide adequate visualization during the operation is of paramount importance. Here are a few pearls for proper handling of the camera and laparoscope and for effective “driving” of the camera:
Practice holding the camera. In general, the non-dominant hand should cradle the camera and laparoscope. The buttons of the camera should always point up.
The light cord is attached to the laparoscope, and in the neutral position, it points up. This is especially important to remember when using an angled laparoscope, since the direction of the light cord corresponds to the direction of the viewing angle.
When “driving” the camera, a good rule to keep in mind is the rule of opposites. To view an image to the right, the camera is moved to the left. Or to view an image that is up, the camera is pointed down. Moreover, the camera should be moved toward the object of interest to provide a closer view. Movement of the camera out (or into the trocar) will result in the ability to get a panoramic view of the field.
When using an angled laparoscope, movement of the light handle results in a change of the angle. Therefore, when the light handle is in the neutral position, i.e., pointing up, the viewing angle is down. When the light handle points up, the viewing angle points down.
The lens can fog once the laparoscope is inserted into the abdominal cavity. This occurs due to the temperature difference between the outside environment and the intra-abdominal cavity. This can be avoided by warming the lens tip in warm water or with the use of antifog solutions [
]. 12 Basics of Instrumentation and Equipment for Endoscopy
Endoscopy in general surgery has many applications and can be used in abdominal or thoracic procedures. This section will provide a brief overview of the common components of endoscopes used for upper and lower endoscopy.
The endoscope is comprised of three main parts:
The handpiece is used to control the direction the tip of the insertion tube is facing, which aids in visualization as well as maneuvering the scope as it traverses a lumen. A large and small wheel is used to either maneuver the tip up-down or left-right, respectively. Turning of the wheel leads to tip angulation in the opposite direction on the monitor. For example, turning the large wheel up causes the endoscopic tip to be directed downward and vice versa. The wheels can be locked in a desired position to aid in diagnostic or therapeutic maneuvers, such as obtaining a biopsy. Buttons on the handpiece control different capabilities. The blue button has two features: covering the port will insufflate air, while pushing the button infuses water. Pushing the red button provides suction. A biopsy port allows for the passage of biopsy forceps or other instruments through the insertion shaft. Camera buttons allow the operator to obtain pictures or videos.
The insertion tube is a flexible cord that is manually manipulated by the operator by pushing, pulling, and torqueing. The deflectable tip at the distal end of the cord has the capability of flexing side to side and up and down via controls on the handpiece. The tip also contains the port sites for multiple applications, including a water nozzle for irrigation, an air nozzle for insufflation, a suction channel, a light source, and objective lens.
The umbilical cord is a flexible tube that contains all of the channels (air/water, suction, and light source) that connect to the tower that houses the video processor and displays screen. The proximal end of this cord is directly inserted to the tower. A video processor cord connects the umbilical cord to the image processor. A water bottle and suction tubing are connected to the umbilical cord to allow for irrigation and aspiration.
The Endoscopy Tower
The endoscopy tower consists of an image processor and display screen, a light source and air insufflator, water irrigation, and energy source. Once all equipment is positioned and connected appropriately, check that the insufflation, irrigation, and suction are working properly before beginning the procedure [