Access to, and development of, working room

Indispensable instruments for accessing and developing the working space include:

? Veress needle (for transperitoneal access only)

? Hasson trocar

? 10 mm trocar with safety sheath

? 10 mm trocars with ventile valve and reducer to 5 mm

? 0? and 30? 10 mm telescopes.

An optional instrument is a:

? Balloon dilator (for extraperitoneal access only).

Basically, there are no major differences between performing transperitoneal or extraperitoneal laparoscopic surgery. However, since the peritoneum is already an existing cavity, it is only necessary to inflate the peritoneum to create a working space. However, since the retroperitoneum and pelvis are not a cavity, it is first necessary to dissect the fat which fills the retroperitoneal space to create a working room.

Thus, in the case of a transperitoneal approach, the abdomen is insufflated by use of a Veress needle followed by puncture with a 10 mm trocar with a safety shield or using an open Hasson technique.

The retroperitoneoscopic approach is begun by making an open canal (15-20 mm wide in diameter) down to the retroperitoneal space, followed by finger dissection (with or without balloon dissection). A Veress needle is not required.

Dissection

The basic indispensable instruments for laparoscopic dissection are:

? Endoscopic curved scissors with rotatable blades

? Endoscopic curved dissector

? Suction-irrigation probe.

An optional but useful instrument is:

? An ultrasonic dissector.

Several dissection techniques may be applied:

? Blunt and sharp dissection with endoshears

? Blunt dissection with endo-peanuts

? Blunt dissection with right-angle dissector (5 mm, 10 mm).

? Blunt dissection with the tip of the suction-irrigation probe

? Sharp dissection with an ultrasonic scalpel.

Haemostasis

Haemostasis is one of the main issues of any surgical procedure. In laparoscopic surgery, there are several guidelines that can assure bloodless dissection. It is of major importance to dissect widely with optimal exposure of the organ rather than a deep dissection. To minimize blood loss, it is better to handle beforehand the vascular supply of an organ to be removed, rather than dissecting it all around and leaving dissection of the vessels as the last surgical step.

The basic indispensable instruments for laparoscopic haemostasis are:

? 5 mm monopolar coagulation forceps/dissector

? 5 mm bipolar forceps

? 10 mm endoclip-applicator

? Endo-GIA? stapler (for large veins only)

? Optional instruments

? Bipolar coagulation forceps/dissector

? Ultrasonic dissector

? Radio-frequency coagulating 5 mm probe.

Suture technique

Laparoscopic suture requires specific training, as it is rather different to open-surgery for both stitching and knotting. There are various methods. Basically, one (sometimes two) needle holder and short-threaded small needles are needed (i.e. thread 15-20 cm long and needles that pass easily through a 10 mm trocar). Specifically designed needles for laparoscopy are useful but not mandatory.

2.3.5 Retrieval of specimens(4)

Finally, an organ bag is essential for removal of the specimen. The LapSac? is the best-tested bag and provides the safest material. This is very important when a tissue morcellation is needed; however, the bag is difficult to handle. Other bags with less resistant materials, but better opening mechanisms, can be used (e.g. Endobag? or Endocatch?).

Date: 2016-06-13; view: 5