Lap instruments & ergonomics

1. DEPARTMENT OF SURGERY
HIMSR, HAHC HOSPITAL
JAMIA HAMDRAD
“LAPAROSCOPIC INSTRUMENTSANDERGONOMICS”
Presenter:- Dr
.MubashirBashir
Deptt.Ofsurgery
HIMSR,HAHCHospital
JamiaHamdard
Moderator:-Prof.P
.K.Ganguly
Professor, Department ofGen.Surgery
HIMSR,HAHCHospital
JamiaHamdard

2.  Gen. Surgery has changed significantly since
introduction of Laparoscopic Surgery in early nineties
 Changes have occurred over a short period of time
 Continued rapidly with increasing use of advanced
laparoscopic procedures.
 Students who opt to take general surgery must be
very familiar with and well educated in this area.
 Be a road roller or become part of the road

3. HISTORY
• 1982 Semm performed first Laparoscopic
Appendicectomy.
• 1987 Mouret performed first
Laparoscopic Cholecystectomy.
• 1990 First indian Laparoscopic
cholecystectomy in mumbai by
Dr Thempton Uduwadia

4. Outline ofPresentation
• INSTRUMENTS
• ERGONOMICS

5. LaparoscopicInstruments
• Handinstruments

6. LAPAROSCOPIC
INSTRUMENT
A
TION
1.OpticalDevices
2.Equipment for creating pnuemoperitonium
3.Instruments for Access
4. Operative instruments
5. Energy sources
6. Tissue approximation/ hemostasis
7. Miscellaneous

7. CAMERA
 These can be single chip or 3 chip.
CHIP: this is also called a charged coupled device in
short, CCD.
 These are flat silicone wafers with a matrix, a grid of
minute image sensors called pixels.

9. LIGHT SOURCE
• Halogen (yellow) or Xenon (white)and LED- cold light
• White balance by making sure white is correct then all
the colours through the spectrum are correct.

11. INSUFFLATOR
CO2 because this has the same refractive index as
air, so doesn’t distort the image and is non
combustible.
 Intra abdominal pressure run between 10 and 13
mm Hg.
 Use disposable filter and tubing for each patient.
 High flow insufflators (35 litres) output
determined by size of outlet.

13. TV MONITORS
• Usually a 20” screen. Now high resolution TV’s
available
• WE can use a standard TV but it must be run
through an isolated transformer.
• More lines of resolution, better detail of picture.

15. TELESCOPES
 Come in varying sizes, laparoscopes usually 5mm or
10mm.
 Diagnostic 3mm scope available but not in general use in
this hospital.
 Made up of a rod and lens system.
 Wide range of angles available 0 and 30 degree are fairly
standard

18. LIGHT GUIDE CABLES
 Different diameters
 Fibre optic cables
 Don’t bend to acutely as will break fibres.
 Check when you plug them in are all the fibres are okay
 Jelly filled cables were used previously to get high
intensity light and was helpful in taking good pictures

21. ELECTROCAUTERY
 types..Unipolar and Bipolar
 Insulation failure of the active electrode.
 Direct coupling of current to other
instrumentation by direct contact.
 Capacitance which may be created by two
electrical conductors separated by an insulator

23. Ultrasonic Energy: (TheHarmonicscalpel )
Uses ultrasonic technology, the unique energy form
that allows both cutting and coagulation at the precise
point of impact,resulting in minimal lateral thermal
tissue damage.
Cuts and coagulates by using lower temperatures than
those used by electrosurgery orlasers.

25. Instruments forAccess
Veress needle:
The Veress needle is designed to create pneumoperritoneum
prior to insertion of trocar in aclosed fashion.
spring loaded , with blunt tip retractable into sharp sheath
penetrating the tissue rather than cutting
Disposable or Reusable
Diameter 2mm and length 80 to 120mm.
Insufllation upto 2.5l/min

27. • Hasson’s cannula:
used for gaining initial access to the
abdominal cavitywith an open cutdown
technique.

29. • Optical trocar: It allows visualization of the
tissues as the blade cuts through the layers
of the abdominalwall.

30. Operative Instruments
Trocars:
-Used to pierce abdominal wall to place
laparoscope or surgical instruments.
-Available as disposable or reusable
- Trocars Can be with flap or without flap
-Trocar tips can be pyramidal, conical or blunt
tipped .
-Size varies from 3 mm to 10 mm

33. Graspers: Retraction may be achieved using large grasping
instruments.
- Duckbill
-Hunter

34. RIGHT ANGLE FORCEP

35. ALLIS FORCEP

36. Dissectors:
Maryland Dissector has long, curved jaws withfine-
tapered tips.
Ideal for precise dissection.

37. L SHAPED HOOK

39. SPATULA

41. Scissors:
There are a variety of scissors for dissecting,
mobilizing and cutting tissues.
straight and curved .
Hook scissors (are used to cut sutures, tough fibrous tissues.)
.

42. Scissors
Hook
scissors

43. STONE EXTRACTER

45. ENDOCLINCH

46. OPEN SUCTION

47. CLOSED SUCTION

48. 3. ClipApplicators:
• Clip appliers are primary modality for ligatingblood
vessels and other tubularstructures.
Disposable clip appliers contain up to 20clips,whereas
reusable clip appliers carry one clip at a time.
Clips are made of titanium though nowabsorbable
clips are alsoavailable.

52. InstrumentsforTissue approximation/Hemostasis
A Pre-tied sliding knot with a loop is available to ligate
stump like structures or tubular structures after cutting.
The suture is looped around the structure to be ligated and the
knot is slid down to close theloop.
Useful in appendicectomy.

54. Mechanical Stapling Instruments:
Laparoscopic staplers are modifications of stapling
devices of open surgery. Staplers are used for
transecting and anastomosing bowel, transecting
mesentery etc.
A range of staple lengths (2.5-3.8mm)is available
depending on the thickness of the tissue to be
divided.

56. ERGONOMICS
• Ergonomics is defined as applying knowledge from human
sciences to match jobs, systems, products, and
environments to physical and mental capabilities of people
in order to promote safety, health, and wellbeing while
performing tasks effectively.

58. 2 D Image
No depth Perception
No tactile feedback
Counter-intuitive
Limited movements
Magnification

59. T
obeanefficientSurgeon…
• Equipments
• Environment
Concentrate on

60. PATIENT POSITION
Produce gravitational displacement of viscera away
from surgical site.
Trendelenberg Rev Trendelenberg
15-20˚ head down 20-30˚ head up
Endobronchial
intubation
Predisposition to DVT

61. Patientpositioning

62. Ergonomics
• StraightLineprinciple
• Triangulation
• Manipulationangle
• Elevationangle
• Lowlyingtable
• Gazedown view

63. StraightLinePrinciple
Surgeon
Pathology
Monitor

64. Trianglulation

65. VisualAxisandMotor Axis

66. Co-Axial Alignment

67. BASEBALL DIAMOND CONCEPT

68. Baseball Diamond Concept
• It has 3 principles:
1. Half the instrument should be in and half out of the
port.(elevation agnle is 60 degree.)
2. Telescope should be in the middle of working instruments
that’s azimuth angle (30 degree) should be equal.
3. Manipulation angle should be 60 degree.

69. Idealangles!
1. Manipulatation angle: 60 degree
2. Azimuth angle: Equal/30 degree each
3. Elevation angle: 60 degree

70. 1. Manipulatation angle: Angle between two
instruments (working and assisting)
2. Azimuth angle: Angle between
instrument(working) and optical axis of the
endoscope.
3. Elevation angle: angle between the
instrument(working) and horizontal plane.

71. Surgeon’sStance
Ideal relaxed stature Tiring

72. Ideal Relaxed Position
-straight head, in the axis of the trunk,
without rotation or extension of the
cervical spine;
-shoulders in a relaxed and neutral position;
-arms alongside the body
-elbows bent to 70 to 90 degrees
-forearms in an horizontal or slightly
descending axis-
-hands pronated (physiological resting
position);
-hands and fingers lightly grip the
handles/handpiece
•Waist line table
•Gaze down view of monitor
•Straight line principle
•Triangulation

73. THANK YOU