Chapter I

Instrumentation and Operating Room Setup

Cristiana Barbosa and Luca Mencaglia
Centro Oncologico Fiorentino, Florence, Italy
 Manual of Gynecological Lagaoscopic Surgery

1.0 Introduction
Modern endoscopy not only revolutionized medical diag-
The integrated device manager enI a ffered by the
nostics, but also paved the way for a new branch of
KARL STORZ ORI" enables specialized or interdisciplinary
opeative technology: minimally invasive surgery. Although
configuration of operating rooms. Predefined individual device
iaparos- copic procedures are performed with few
settings allow OR capacities to be used more efficiently
instruments, technology remains very important,
and ensure that scheduled operating times are adhered to.
considering the significance of the interaction between the
The central networking of hard- and software components
surgeon and the instruments. Knowledge of the
in the KARL STORZ OR1” is the modem and efficient
instrumentation allows the surgeon to overcome a series of
appraach to device communication, and allows complete
dysfunctions or malfunctions that arise quite frequently in
control of the entire endosapic operative procedure from
laparoscopic surgery. Rec@tiy, computerized designing of
within the sterile area. The simple and aordinated control
laparoscopic instrument has bacome commonplace and
of the devices via central panel control, touch screen or
microprocessorcontroited safety features have been added.
speech control accelerates the operative procedures and
Now, rapid growth of minimally invasive surgeiy is virtually
reduces the risk of incorrect equipment usage during the
unstoppable and new procedures are added almost daily.
intervention.
Laparoscopy is quite technologically dependent and every
surgeon should have a reasonably good knowledge of The standardized KARL STORZ Uommunication Bus
these instruments before starting surgery. (SCB) Interface !orms the basis for using the entire
system. Endoscopic devices, such as video cameras, cold
light sources, insufflators, suction and irrigation pumps as
KARL STORZ has developed an operating room concept well as the operating table, blinds and operating light are
which is tailor-made to meet the requirements of this type controlled via the SCB.
of surgery. With the design ol system worMtations, KARL
An integrated digital recording system simplifies archiving
STORZ OR1" has set a new standard for harmonizing
of image, video and audio data of important surgical steps
individual surgical procedures, thus reducing stress for
and results. This information can be used !or both patient
surgeons and medical staff. On account of the fact, that
documentation and scientific evaluations. Connection to
the saved time can be spent on coordinating tasks, more
the Hospital Information System (HIS) and Picture Archiving
time is available for the patient and, as a result, medics
and Communication System (PACS) optimizes quick
treatment of a continually high standard is guaranteed.
access to patient and image data.

The e/em arrTiguration of the operating room ORJ* (KARL STOFtZ Tutllingen, Germany.
Manual of Gynecolog icai Laparoscopic Surgery 9

In addition, telemedicine applications. such as video confe— human vision. The HD video Image can be simultaneously
rences leatur ing live operations for teaching and training displayed on all cross-linke‹J HD video monitors of the OR or
purposes, can be controlled directly kom the sterile area clue adjoining rooms.
to the integration of state-of-the-art audio and video t9Ch88- The modular design Of the system makes it possible to
!8gY- *8!8 8!88 8!!8^8 !88 ‘v'rtual P"8888*8’ 8! 8 ren"otelY integrate cents aJ panel control, image recording and archiving
Placed 8*P8*› ^88 would 88 88!+ !* Provide 8 8+8888 as well as telemedicine into an existing operating room step 8P!
8!88 !8 *8 88g8!8g live oPerative Procedure. by step. Thanks to the open system architecture, KARL
Using a KARL STORZ OR1” with integrated high-definition STORZ ORI " also guarantees opt imal utilization of the
(HD) technology is of added benefit to surgeons, clinical staff polential offered by new technology, including future medical
and patients alike. The HD imaging platform enables visuali- developments. The integration of additional devices from
zation via HD widescreen flatpanel monitors with a maximum other mansifacturers is made possibl e by use ng In tertace
resolution of 1920 x 1080 pixels at 16:9 aspect ratio offering standards.
a more natural, panoramic view, that reflects the anatomy of

2.0 Techniques for Creating the Pneumoperitoneum

and Abdominal Access
Lapai oscopy is a technique that allows viewing and surgical can be placed after successful creation Of the pneumoperi—
manoeuvres tO be performed on abdominal viscera through toneutr with the aid of a Veress needle, either by blincl direct
an incision ol less lhan 1 cm. Pelvic visualization is much insertion of the trocar. or by an ooen iaparoscopy appraach.
betfer through the laparoscope than in tradit ional surgery, /\Üdominal access techniques used in laparoscopy are either
WÑICÑ k9OUt790 an access 0 O0tÜQ OI S9YOkBl C9Üt tT9tk96. a c|osed @p @pqç access (also known as @ppç ]@gp@çç@py)
Creation of the pneutroperitoneum is. with the exception In the cl osed access, the piJeumoper itoneum is created
O f gas less Iaparoscopy, a prerequisite for perfor mmg by using a Veress need le and the primary trocar. This is a
laparoscopy correctif. A Veress needle and an insu fflator are blind technique and most commonly practiced as a ireans
needed. lt is important to note, that this is a blind procedure of access by surgeons and gynecologists worldwide. Open
with the risk of complications arising frais the accidental access is the direct entry without creating a pneumoper1to-
puncture of bowel or vessels. neum; the insuf flator is connected aÏter the trocar has been
The positive pressut e o the pnQ#ty@ÇQy| tQçQç/ gtçQ$ tgq inserted in the abdominal cavity under direct endoscopic
surgeon numel ous advantages, such as space, dissection "!8!
and hemostasis. The ti ocar accomodating the endoscope

Fig. 1b Fig. 1c
Overlnead boom system in an oberating room. Because the
equipment hangs from the ceiling, it does not interfei e with perlpheral systeme via touch screen in the sterile ares.
10 Manual a f Gynecological Laparoscopic Surgery

3.0 Instrumentation
3.1 Veress Needle

Disposable and reusable Veress needles for creating a pneu-

The reusable type should be preferred to reduce the costs
moperiloneum are available (Fig. 2).
of laparoscopic surgery. Veress needles are available in
The \/eress needle is used !or creating the initial pneumo- three lengths: 80 mm, 100 mm, and 120 mm. In thin
oeritoneum. A trocar can be introduced safely because the patients, with scaphoid abdomen. a 80 mm-Veress needle
distance of the abdominal wall from the organs is increased. should be used. in obese patients, a 120 mm-Veress needle
The \/eress needie technique is the most widely practiced is preferred. Disposable needles do not require cleaning or
method of access to the peritoneal cavity. The Veress ster ilization procedures. The Veress needle must be kept in
needle compr ises Mo componen ts: an outer hollow needle perfect condition to ensure that the mandrin slides easily
with a sharp beveled edge, and an inner, spring-loaded, into the protective sleeve. The surgeon must have full
retractable blunt oblurator with the stop position beyond the knowledge o! all safety features of the mandrin. The Veress
tip of the follow needle. Once the oeritoneal cavity is needle should be held between the thumb and the index
entered, the blunt obturator juts forward by the spring-force finger during insertion. When the needle is inserted through
and protrudes beyond the tip of the hollow needle, thus the abdominal wail, passage through the fascia into the
preventing from iatrogenic visceral and vascular injures. peritoneal cavify can be recognized as a tactile “popping"
sensation (Figs. 3, 4).

Fig. 3

Fig. 4
Entry oT the Veress needle through the fascia into the peiitoneal
[Link] Gynecolbgical ‘[Link] ’11

Sub umeov ai

The umbilical area is preferred for introducing the \/eress

needle, because the thickness of the subcutaneous and
pregeritianeal tissue layers in this area is reduced. In terms
of cosmetic results, the umbilical fossa is cabable of
ooncealing the postoperative port-site scar (Figs. 5a, b).
Prior to laparoscopy, the abdomen is prepared and draped
to establish a sterile field (Fig. 6}. Before the \/eress needle
an be inserted, a transverse or vertical percutaneous
incision is made large enough to accommodate the primary
trocar. (Figs. 7, 8). The base of the umbilicus io the thinnest
area o! the abdominal wall making it the preferred site for
insertion of the needle. To move the large vessels out of the
way, it is advisable to elevate the abdominal wall during
penetration by the needle. The abdominal wdl may be lifted
by fiand or by grasping it with a forceps. The needle is
inserted at an oblique angle toward the uterine lundus.

Prior to laoa the abdomen ie prepared and draped to

Ftp. 0 ’ ’
The uméliQJs in grasped viii an atraufnatTc
A transverse or vertical percutaneous inclelon ie ma6e.
fomepe.
12.'

Overweight patient.

Care must be taken not to angle the Veress needle laterally

!oward the iliac vessels. The insufllation stopcock of the
needle must be opened to allow inflow of air as soon as
the perJtoneal cavity is entered by the tip of the needle
(Figs. 0a-c). The negative pressure of the peritoneal
cavity allows the undelyng structures to fall away. Proper
intra- peritoneal placement ol the \/eress needle must
always be

5.1 Safety Teeta

Irrigeéon and aspiration tast• the mast widely used safety
test is performed with the aid of an empty syringe or one
containing physiological saline (Fig. 10). It consists ol three
steps. The first steg is aspiration, which must not produce
air, liquid or pus, thereby asoertaining the absence of
Sq. 9s ’ vascular, urinary or intestinal perforation. )n tbe second
*“ Obeee
patient. steg, 20 cc of air or fluid is injected. There should be no
resistance felt, and fluid should not be able to be aspimted.
It is an easy method of confirming that there is no contact
with intra-abdominal viscem or adhaions. The third steg is
an attempt to reaspirate
!he injected air or liquid. Reaspiration must be impossible,
confirming the prope intraperitoneal placement of the Veess
needle. Howeve, It the needle is in the pre-peñtoneal sgaoe
or in the muscle liber above the rectus, the inj«ted solution
can be reasprated. At the time of the aspiration lest, if more
fluid than previously injected becomes apparent, The surgeon
should suspect either ascitis, urinary bladder perforation,
or the presence ol a cyst. In the presence of fecal material,
perforation of the small or large bowel should be suspected.
II blood is visible, then iatrogenic vessel iniury may have
occured. If any tesh blood or fecal fluid is aspirated in the
syringe, the surgeon should not remove the Veress needle,
and emergency laparotomy is reguired. Leaving the \/eress
needle in position helps to localize the punctured area after
laparotomy, ar›d facilitates subsequent hemostasis.

San tost to ccritirm the proper placem' ot of the Ven needb.

[Link] Gynecological [Link]

The irrlmabdominal irisufllation pressure ohowr‹ on the font panel

of Ihe ELECTRONJC ENDOFLATOFI* is i riW.

Hanging drop test: a few drops of physiological saline inside the e'mentum, or in the bowel. On the other hand, if
should be poured over the Veess needle and the more than 5 L c'f gas is administered without any distension
abdomind wall should be lifted slights. If the tip of the of the abdorrien, this signds probable leakage. Jhe
\/eress needle is inside the abdominal cavity the hanging abdomen needs to be checked for distension during
drop shouid be drawn inside because of the abdomen's instillation. With more experience, the surgeon will
negative pressure. II needle point is anywhere else, the immediately realize If there is any error by anstantly
hanging drop test will be negalive. monitoring tfiese four insufflation parameters.
Get inzufgation test: the lunctionai range of a modem Alternative sfteo for Vereso needle insertion are: the left
electronic insutflator pemits the proper placement of the upper quadrant, left iliac tossa outside the rectus muscle,
\/eress needle to be checked by use of the unit alone. For and the posterior pouch of Douglas. For the left upper
this purpose, the how rate must be set to zero, and the quadrant, a tine is drawn from the mid-clavicular point to 2
ins/- Elation pressure must be set to the chosen value. cm below the tell costal margin. After vertical insertion of the
The unit is then activated and the actual pressure value is Veress needle, routine checM are made. Insertion into The
read. This reading must be negative or at least zero. lelt iliac fossa must be performed outside the rectus muscle
confirming that the needle has been positioned correctly. of the abdomen to avoid inture to the epigastric vasels.
Once this has been confirmed, the flow rate can be Jnsertion in the pouch of Douglas is relatively simQe. After
increased to approximately lifting the cervix with a teriaculum forceps, the needle s
2.5 liters per minute (Figs. 11, 12). Pressure values of less inserted 1 cm inferior to the ceryJco-vaginal junction.
fhan 8 mmHg are compatible with intraperitoneal positioning Because the true in this area is very thin (less thao 1.5
of the needle. In the case of higher pressure or reflux of air cm), insertion is usually accomplished early. A safely test
or fluid, tkie needle should be repositioned rather than must be pertarmed before establishing the
préssed forward. For safe access, the surgeon should pneumoperitoneum. )n some instances, the
meticulously monitor the four insuftlation parameters at the \/eress needle can also be inserted by transfixing the uterine
time the pneumopesitoneum is established, i.e., preset fundus. In this case, after application of a tenaculum forceps
inooffla on pressure, actuel intraabdominel pressure, get and measurement ol the uterine ca?ty by use of a palpation
how rate and total volume of gas inflow. During insufflation, probe, the needle is passed through the cervix, the cervical
there should be a proportional rise in actual pressure value. canal, the endorrietrial cayify and the wteine fundus into the
For example, assuming only 400 to 500 ml of gas are peritoneal cavity. This approach is contrair›dicated in cases
adminis- tered, if the actual pressuré is equeJ to a preset of infertility, previous myomectomy, and tentative diagnosis
pressure of 12 mmHg, then the gas is not going into the free of endometñosis of the pouch of Douglas.
abdomind cavily. Rather, it may be located In the pre-
peritone+d space,
14 Manual of Gynecological Lagaoscopic Surgery

” - a-

Tfig. J3 ”
The COC in uGlation unil ELECTRONJC ENDOFLATOFI*,
The C,C Tosufflalion unit THERMOFLATOFI* wJlfi integmted CQ
healing, filtering, and humidII'/ing system (KARL STOFtZ Tulllingen.

4.0 Units
4.1 Electronic COC EndofTator
Tbe electronic CC+z endoflator is an insufflation unit used
the troe intra-abdominal pressure can actually be
for delivering carbon dioxide to the peritoneal cavily in Tapa-
determined by switching off the insuf1lator flow for a
rosapic operations (Fig. 13}. The main technical features
moment. Many good quality microprocessor-controlied
include the unit's capability to insufflate up to 1M0 L/min.
irisu1llators deliver a puTsatile flow of gas when the \/eress
(THERMOFLATOR max. 30 L/min.) and to maintain a constant
needle is connected, in which the low reading of actual
intra-abdominal pressure without exoeeding the safety limit
pressure measures the true intra-abdominal pressure.
of 12—16 mmHg. Continuous control of intra-abdominal
Actual pressure should not exceed 25 mmHg because this
pressure helps prevent complications related to an
can result in compression of the infeior veoa cava which
incorrectly positioned \/eress needle {gre-peritoneal
compromises venous return to the heart and entails an
emphysema, or puncture of the ornentum, bowel and
increased risk of deep vein thrombosis and reduced cardiac
vessels). Patient safely is ensured by optical and acoustic
output. There is an elevated ñsk of air embolism due to
alarms as well as several mutually independent safety
venous intravasation and an increased incidence mte for
circuits. The set-point values for pressure and flow rate can
surgical emphysema.
be preaaju•ted exactly using jog keys and digital displays.
For safety reasons it is mandatory that the user have a The flow mte reflects the IIow of CQ through the insufflator
sound understanding of The functions and quadro- tubing. When the \/eress needle is attached, the flow rate
manometric insu11lation parameters. These lour insutflation should be adjusted to 1—2 liters per minute. The Veress
parameters are: preset insufflation pressure, needle may be inadvertently inserted into a vessel. But if the
actuel intraabdominal preocure, gas flow rate and totel flow rate is low, there is less chanoe of serious comQication.
ypjqm# @ g@ ¡/jqg,
Onoe tfie initial pneumoperrloneum has been established and
the cannula is inside the abdominal cavity, the gow rate can
The preset instillation pressure is adjusted by the surgeon be set to maximum to ampensate for loss a! CCiz caused
before starting insufllation. It should be apgroxTmately 12—14 by intraoperative use of suction-irrigation cannulas. II is
mmHg without exceeding 1&-20 mmHg. Microprocessor- important to bear in mind that it The insutflator is set to its
controlled insufflators automatically maintain intra- maximum gow rate, then it will allow flow only if the actual
abdominal pressure at the preset value. Whenever intra- pressure is less than the preset pressure. Otherwise, II will
abdominal pressure decreases due to gas leakage to the not pump any gas. Some surgeons limit the initial flow rate
outside, inflow of gas will be increased to keep the intra- with the \/eress needle to 1 liter per minute. As soon as it is
abdominal pressure at the preset level. If intra-abdominal confirmed, that gas delivery to the abdominal cavity is working
pressure increases due to external prasure, the insufflator appropriately (percussion examination and seeing obliteration
removes some gas from the abdominal cavity to again of liver dullness), the 11ow mte can be increased. Normal cali-
maintain the preset prasure. ber Veress needle can deliver OOH flow at a maximum of 2.5
liters pet minute. With a COC gow mte ol more than 7 liters per
Actual pressure is the actual in//a-addomina/ pressure
minute delivered through the cannula inside the abdominal
measured by the insufflator. When the \/eress needle is
cavity, there is always a risk of hypothermia to the patient.
attached, Ihere is a degree of error in the actual pressure
The latest generation of insul1lators has a gas heating, filter-
reading because of resistanoe of gas gow through the small
ing, and humidifying system offering the following benefits
lumen of the \/eess needle. Because the continuous flow of
ampared to standard insu11lation devices: patients maintain
insufllating gas through tfie \/eress needle usuaJ\ gives an
a warmer core body temperature; logging of the dish lens
extra 4 to 8 mmHg of measured pressure by the insufflator,
 15

rig. 1s mmHg. This keeps fhe vessels out of tfie way, while
Heueab1e ebarp trocar wttn 9yramidal bp. avoiding dimpling of the abdominai wall

is reduced; less pastoperative pain. Such a system is

indis- pensable if a how rate of up to 30 lites per minute is
used
{Fig. 14).
The total volume of insufflated gas is tfie fourth parameter.
In a normal-sized human abdominal cavify 4—5 liters of
COC are required to create an intra-abdominal actual
pressure of 12 mmHg. In some large-sized abdominal
cavities and in

5.0 Trocars
Trocars parnit acers to the intraperitoneal cavify (Figs 1/
16). The primary trocar accomodating the laparoscope is
usually introduced via the umbilicus. h can bo introduced
blindly after creating the pneumoperitoneum by use of the
Veressoeedle (closed access). Inthis case, it is
recommended that the peritoneum be created by
insufl1ating up to an intra- abdominal pressure of 15
16 Manual of Gynecological Lagaoscopic Surgery
F@. 16
Before prooeeding wilfi the primal Pocar Qa¢ement, the abdominal

FJ. 10
Tlne bp of fbe Jrocar is pastel through the taecia

multipara patients, delivery of 6—7 liters of COC (rarety 8

ta 9 liters) is ocassionatiy required to attain tfie desired
pres- sure of 12 mmHg. Wheneve It+ere is less or more
amount of gas used to innate a norm+d abdominal cavily,
the opemting surgeon should suspect some error related to
pneumogerito- neum technique, suoh as c+eation ol a pre-
peritoneal sgace or extravasation of gas.

during trocar insertion. At this point, removal of the Veress

needle is followed by primary trocar insertion. When
passing through the fascia arid protruding into the
abdominal ¢avity, the surgeon should fiave the typiai tae:tile
sensation. Correct trocar insertion depends on correct
superficial incision, trocar axis ar+d correct intra-abdominal
pressure. In some patients, it can be useM to lift the
abdominal wail by har+d or with an Aliis forceps (Fig 17-
10). After insertion, the position of The
 15

The operating aroecope Fttled with a video camera in inserted fo

Fig. M

v«w›,it ii iuoamgvmdexxxxydiui,N

trocar must be confirmed by introducing the laparoscope the accessory tracers must also be adapted to the instru-
and inspecting the pelvic cavity (Fig. 20). Direct trocar ments selected. Prior to the insertion of accessory trocars,
insertion without pneumoperitoneum is reported to be safe, the patient is placed in the Trendelenburg position and the
with no more complications than those associated with the trocars are introduced under vfsual control. The number,
anven- tional technique. This method for creating the size and position of accessory trocars are predetermined by
primary laparo- scopic port is usually applied by the fype of surgery. To avoid TatrogenTc injuries to epigastric
gynecologists In the case of s sheseoliwaeng houdbeshwV0§dgiâ
roscopic-guided sterilization procedures. palpation and transillumination of the abdominal wall (Figs.
21, 22). It Ts very important that trocars be equipoed with
Trocars should behad safely and comfortably in the
a retention mechanism to prevent inadvertent slippage or
surgeon's dominant haod so that the proximal end of fhe
dislocation of cannulas during surgical maneuver or when
trocar should rest on the thenar eminence, the middle
changing instruments. Reusable mets canullas are
finger should rest ove the gas inlet with the index finger
equipped with leaflet valves that can be opened manual ly
pointing towards the sharp tip of the trocar. Applying
when introducing or removing ao instrument. In this way
controtted, constant force, the trocar is advanced through
damage to delicate instruments like the distal endosape tip
the abdominal wall using a slight twisting motion. The main
or blunting of sharp instruments (e.g., scissors) can be
axis of trocar insertion must be in cranio-caudal direction,
prevented. To prevent leakage of COC while operating
the angle a! inclination relative to the perpendicular ranging
with a 5 mm-insfru- ment through a 10 mm-trocar, the use
between 30‘ and '46‘.
a! a specific cannula reducer with automatic valve is
The size of the primary trocar must be adapted to the required.
diameter a! the laparoscope to be inserted. The size of
Manual of Gynecolog ical Laparoscopic Surgery

Tracers are available with various tip designs: the conical

tip, pyramidal tip. and blunt tip (Fig. 23). These are chosen
depending on the surgeons exoerience and preferences.

Fig. 24a
The working c1nannel ol an optical ’v'ereos needle is large enough to Fig. 24b
The miniature endoscope inserted in the optical Veress needle

When extensive intraabdomi nal or pelvic adhesions are

susoect ed particular aftention must de paid to the site of
trocar insertion. In these cases, a miniature endoscope can
be used through the working channel of an optical Veress

the primary trocar. The needle is inserted using the

technique descr ibed above. Before starting insufflat ion
correct place- ment of the needle is confirmed by means a f
the miniature endoscope. Once the pneutroperitoneunJ has
deen induced, the same endoscope will be used for visually
contra fled insertion of the pnmary trocar (Figs. 24a, b).
18 Manual of Gynecological Laparoscopic Surgery

An akemative technique is the visually controlled entry. The

technique commonly involves the use a! a reusable visual 11
mm-cannula system, and a 0°-endoscope that provides direct
visualization a! the entry tract and may be chosen for creation
of the pneumoper itoneum in patients with a previously
scarred abdomen. To name only a few of the devices avail-
able on the ma+feet, such as TERNAMIAN EndoTlP” tracers
(Endoscopic Threaded Imaging Porlj and Visiport or Optiview

The EndoTlP" trocar is inserted under endoscopic guidance

via a small incision without prior creation a! a pneumoperito-
r›eum. By applying clockwise rotation the EndoTlP” trocar is
slowly inserted through the various tissue layers. The
\/isiporI optical trocar cuts through the tissue planes with
a blade at the tip. This can be visually controlled via an
endoscope inserted through the trocar. All visual trocars
have in ammon, that they can reduce the risk of injury to
intra-abdominal organs given prooer application by an
experienced surgeon (Figs. 25, 26}.

The schematic drawing illustrates the major beneffls of the TERNAMIAN

FndoTlP° Cannula System:

¥ The TERNAMIAN EndoTlP" System contains neither oharq oo!rits nor a cutt!ng
lrc'car which e inn nates the risk of inadverlerrt in uries to the atierrt.
Manual of Gynecological Laparoscopic Surgery 19

6.0 Endoscopes
A state-of-the-art endoscope must produce images of
the surface of internal organs. It has been subject to
concealed body cavities and meet the highest demands in
continual further improvement and yet remains the
terms of brightness, depth of focus, magnification, contrast
undisputed gold standard in the !ield of medical imaging
and resolution. The major cornerstone for optimal image
technology.
transmission in endompy was laid by the introduc4ion of the
rod-leos system by Professor HaroldH. Hog/‹ins. Endoscopes are available in various diameters and lengths
Recognizing the significance of Prof. Hopkins invention, the (Fig. 2/. Miniaturized telescopes should generally be used
instrument manufacturer KARL STORZ signed a licensing for diagnostic laparoscopy, with the intent of being less
invasive for the patient. For micro laparoscopy a 1.2 mm-
agreement with him in 1965 that founded a long-standing
telescope can be introduced directly through the Veress
successful collaboration. The combination of rod-shaped
needle. To meet the demands of gynecological endosapy
biconvex lenses with meniscus lenses delivers, first a! all,
the basic equipment must comprise a powerful cold light
superior image brightness, and second, a sufficiently good
source and endoscopes that are capable of providing high
compen- sation lor image errors such as astigmatisms and
quality close-up views of the organs. An optical Veress
Image field curvature that disturb image transmission
needle is recommended in patients with suspected or
systems. The HOPKINW rod-lens system provides
known adhesions or history or presence of umbilical henTa.
substantiâ advantages compared to a conventional lens
5 mm- telescopes may also be used for simple diagnostic
system: improved resolution and contrast, large angle of
lapa- roscopy. For operative laparoscopy, 10 mm-
vision, extremely clear and highly realistic images that
laparoscopes are preferred because they ofler sharp and
permit to identify the smallest details on
highly detailed images both in panoramic and close-up view.

Fig. 28
aoouo a aparoscopes. HOPIONS* rod-lens IaparoWopee are available with dilTererrt angle
of view.

The straight forward laparoscope with 0° angie of view is

major drawbacks of minimally invasive surgery are loss of
generally preferred by gynecoiogists, who always work in
degth perceotion, reduced tactile feedback and deficiencies
the pelvic region tFig. 28). The 30° forward-oblique
in eye-hand coordination. These days, rriost of the surgeons
iagaroscoge permits far greater latitude for viewing
work on the basis of virtual 2D-video images via the monitor
underlying areas in the case o1 difticult anatomical
screen. Undoubtedly, 3D-visualization of the operative field
conditions. Flexible fiberscopes allow the angle of vision to
still remains or›e of the greatest challenges. Specific
be adiusted by active deflection of the distal tip according to
research and development efforts should be intensified to
the indivT dual anatomical situation or the needs of the
further improve the technology in terms of depth of
intervention; they are used more frequently Tn the digestive
perception, qualify of stereoscopTc vision and ergonomics.
tract or for tumor surgery. The
20 Manual of Gynecological [Link] 'apic Surgery.

. 7.0 Videoendoscopy
In modem laparoscopy, a high quality video camera should
always be used. Surgeons must be adequately trained until
they are proficient with the techniques of video laparosoopy
usually performed in a comfortable standing position while
watching the video sc+een (Fig. 20). There are various
types of video cameras available on the market. The
technical criteria of a good video camera are: resolution
(number of lines or pixés), sensitivily (lux), number and
quality of video output ports. Finally, a high signal-to-noise
ratio (SNR} can be associated with focal interference
patterns that adversely af4ect image quality in extreme
situations, i.e., in the case of bleeding and in critical lighting
conditions.
The video camea used in laparoscopy usuaI\ needs to be
focused prior to insertion into the abdominal cavity. At the
time of focusing it should be placed at a distance of approxi-
mately 5 cm away from the target area. This is the average
distance most frequently used during Taparoscogic surgery.
White balance calibralion of the video camera needs to be
performed pñor to starting the surgicâ procedure and
placing the laparoscope (with mounted video camea) in the
primary port. The usual method is to direct fhe laparoscope
tip at a
white obi ' and trigge the automatic white balance mode,
either via the !ront panel ar the push-button on the camera
head. The white object is taken as a souroe ol reference to
adjust the camera- to the primary colors (Red, Green, Blue;
RGB). The additive combination of the thrée primary colors
in equal intensities produces white.
The-core component of a video camera is the CCD
sensor, a solid-state chip embedded with a seias of tiny,
tight- sensitive photosites capable of producing varying
amounts of charge in response to the quantity ol incident
light. Lapa- roscopic video cameras are typically avgilable
in a one-chip or three-chip configuration. In one-chip
video cameas the three primary colours are captured by a
single chip (Fig. 30}. In three-chip cameras a beam splitter
separates the light into the three primary colors. In this
L STORZ Tutttingen. Germany). way, each color is captured by a sepamte cfiip. Any color
can be produced by a simple additive mixture of the
correct proportions of red, green, and blue light. Three-
chip video cameras have a very high resolution and
provide superior image quâify (Fig. 31).
In 2002 the first generation of pure digital image camera
systems, such as IMAGE1” wee introduced to the market.
Ranking among fhe first medical-grade video camera systems
with digital source sampling technology (DSS), the
IMAGE1” camera system instantly converts optical images
to digits at
!he CCD sensing chip. Owing to its all-digits circuitry across
the entire imaging chain the IMAGE1"camera system drivers
”“ high-resolution video images of excellent qualify, accurate
color rendition and contrast. This innovative technology
has laid the foundation lor lurthe development and inte-
gration of HD-compatible components (Fig. 32). Additional
information on this highly topical issue will be given
below., The CCD sensor ol the standard IMAGE1“ 3-chip
camea head captures 752 x 582 pixie per chip. Camera
1unctions are programmable via the camera head
buttons.
Manual of Gynecological Laparoscopic Surgery 19
[Link] Gynecolbgical ‘[Link] 21

There is an increasing need for recording and storage of

digital data generated during videoendoscopic-guided
surgery. Digital still image, video and audio file of the major
steps of a surgical procedure are used for consultation,
review and medicolegâl purposes. Besides, they can
provide a powerful tool in educating surgeons and
students about new and developing procedures. Digital
technology has already replaced many classical
documentation methods, such as making hardcopy
pñnts with a video color printer (Fig. 33). Telemedicine
permits rapid access to remote medical experts by
means of teleammunication and infor- mation
technologies. With the deveJopment of the integrated
ogemting room, digital data archiving and global computer-
based communication technologia can be used for various
purposes, thus enhancing the real-time multidisciplinary
exchange of scientific information including remote
diagnosis and therapy as well as remote education and
training.
to a laparr»x›ope. In the background, the IMAGES- HD hub
The Advanced Image and Dafa Archiving System (KARL STORZ camera confrol unit (CTRL STORZ Tuttlingen, Germany).
AIDA* compact NEO) allows the efficient and convenient
digital storage of all patient-related text, audio and image Optimal visian is of paramount importance to the
data including video sequences. lntraopeatively acquired successful outcome of any surgery. The wo+id's largest 23"
data can be elTiciently archived on DVD, CD-ROM, USB J1at screen LCD video monitor is idea4y suited to meet this
stick or on the network. Optional connection to the HIS and demand. The 16:9 widescreen display improves
PACS optimizes fast access’ to patient and image data. anatomical orientation ur+der difficuk-situs conditions in tfiat
Digitally stored image can be processed and can be it provides an extended periphemi view compared to the
integmted into a referring report or scientific documentation standard 4:3 aspect ratio. In this way, visualization ol the
{Fig. 34). more lateral aspects ol the image is enhanced, which
facilitates instrument handling and praise positioning (Fig.
High-definition video technology is gaining widespread
35a). images acquired through HD video endoscopy are
use in the consumer segment and bears !he potential of
capable of emuiatir+g 3D views because
improving the quality of videoendoscopic imaging and
documentation. Tn response to the mai° !••P forward in
fiigh-definition imaging technology, one of the world's
leading manufacturers of medical devices has developed a
video platform that allows step-by-step integralion of HD
visuali- zation components ar+d image management
systems Into the ageating room Imaging chain. The new
HD video platform iMAGE1” hub (KAFtL STORZ
Tuthinges, Germany) with its inherent resolution of 1920 x
1080 pixels ofTers images of superior quality that allow the
user to distinguish even the finest tissue structures c” '’
including the vascular capillary network. As compared to
The standard image resolution of the current PAL system,
the iMAGE1" HD platform is capable of delivering f+ve
tirries more image information per seoond.

*- .
22 Manual of Gynecological Laparoscopic Surgery
Fig. M
ed véeocart w the BARL STORZ ANDA* combos
 [Link] Gynecolbgical ‘[Link] 21

interlaced scan daft-frame} dlsdays 26/30’ frames per second.

they provide a higher depth perception and color contrast

of image information at 50 Hz (Imme rate) as compared to
that help surgeons better differentiate anatomical planes.
systems that use the 1080i video mode (“i™ stands for
Structures that are normally invisible on standard definition
“inter- laced”) (Figs. 35b, c).
images become more distinguishable and can be
recognized more easily. Due la the short response times of In contrast to the 1920 x 1080 progressive scanning mode,
the LCD elements used in the newest generation of HD fiat the interlaced mode completes the scan process only for
screen monitors a steady stream of crisp clear images is every second line at a frame rate of 50 / 60 Hz, which is
why two complete scans are required in the interlaced
delivered so that even fast-moving obi ts are displayed
scanning mode to display the entire image. Progressive
without motion lag, ghosting or other artefacts, commonly
scanning technology not only creates images of superior
experienced with standard display technologies. quality but is of added value in terms of data storage.
The KARL STORZ iMAGE1" HD hub platform uses 1080p The image acquisition and display slandard of the IMAGE1”
technology, which is currently the highest-resolution format HD hub platform involves the use of the high-definition
for broadcasting and distribution of video content. The IMAGE1" H3 three-chip video camera which offers the major
1080p (“p” stands for “progressive scan”) video mode of advantage of a more natural color performance for brilliant,
the IMAGE1" H3 video camera delivers double the amount high-contrast images of almost three-dimensional
appearance.
Manual of Gynecolog ical Laparoscopic Surgery

8.0 Video Monitor

In the past, endoscopic procedures were performed without
the aid of video monitors. The operating surgeon visualized
the interiors of the patient only by clirect observ ation via the
endoscope eyepiece. This method was associated wilh
many drawbacks, such as the use of monocular vision, lack
of appropnate real-time assistance, poor magnif ination
proper- ties and a limited range of feasible procedures that
produced equally good, or even better results as compared
to the standard approach. The inti oduct ion of television
and the advent ol information technology that propelled the
develop- ment of medical imaging systems have, not at
least, had a considerable impact on laparoscopic surgery.
These are |ust a few of the benefits that ha'ye boosted the
development of lapaJ oscoplc instruments and surgical
techniques: improved magnification properties, real—time
interaction between the operating surgeon and other
members of the sui glcal team, binocular vision that permits
highly complex procedures to be performed.
Surgical monitors operate on the principle of electronic
horizontal linear scan wing (Fig. 36). Each picture frame
consists of a given number of lines, depending on the tyr›e operate at G25 lines of resolution. The final image depends
of system used. The world is cur+entry clivided into three main upon the number of lines a f resolution, scanning lines
analogue television broadcasting standards: PAL, SECAM and pixels How many black and white lines a system can
and NTSC. NTSG (National Television System Gommiftee) differentiate is expressed by the lines of resolution. These can
with '525 lines of resolution, is the analog I elevision system be horizontal or vertical. Horizontal resolution is defined by
used in the United States, Canada, Japan and some other the number of hoñz ontal elements that can de reproduced
coun tries. In most countries of cen tral Europe except on the monitor, sometimes mixed up with the number a!
for France, the PAL (Phase Alternation Line) system is in vertical lines. The term “pixel” denotes the number of picture
use. elements that accounI for image de(inition. Briefly spoken,
The French system is called SECAM (Sequentiet Couleur the higher the pixel count / resolut ion, the better the image
â Memoire). Both the PAL and SECAM television systems quality.

9.0 Cold Light Source and Cold Light Cable

Minimally invasive surgery in genei al, and video
laparoscopy in particular, require that an adequate level of A typical light source comprises a lamp, a heat filter, a
illumination be maintained at the operating field throughout condensing lens and manual oi automat ie intensity control
the procedure to make sure that the surgical team can circuit. Ne type of lamp is the most important component
clearly visualize anatomical structures and control the of the light source because it determines the quality of light.
delicate movements of Instruments. The quality level a! a The two most frequently used types of lamps are Halogen
cold light source is deter- mined by the quant ify of light and xenon. The iighl emit ted by a xenon lamp is more
natural compared with a halogen iatnp Halogen bulbs are
available at each step of the electrooptical system. The
low voltage and have an average life cycle of 50 hours.
luminous efficacy of a lamp is the quotient of the total
These lamps are inexpensive and can de used for
luminous flux emitted (light output) divided by the total lamp
laparoscopic sui gery i! a low-budget setup is required.
power input. However increasing the power causes a real
Xenon lamps consist of a spherical or ellipsoidai envelope
problem with regard to the generation of heat. At present the
made of quaM glass, which can wittnstand high thermal
technical improvements made to video cameras means that
loads and high internal pressure. For uitinnate image quality,
It is possible to return to reasonable power levels. 175—250
only the highest- grade of clear fused silica quartz is used. It
wafts are generally sufficient for routine endoscopic
is typically doped, though not visible to the human eye, to
procedures. For special agplintions, or when using miniature
absorb harmful UV radiation generated during use. Xenon
m«ops,a od£gni oumso+£oowat ›«xomm ndea light sources yield the best results.
to iJJalntain a sufficient level of illumination in the abdominal
cavities. This applies all the more in view of tfie fact that even
»to Lxdngmy srmpamdMcondxlomgnl>ni
light absorption (Fig. 37}.
24 Manual of Gynecological Lagaoscopic Surgery

Prope white balance calibration before the start of an o|

essential to test the equipment, particularly if assemblies
aera- tion Ts a very good practice for obtaining a natural
including components !rom different manufacturers are
color. White light is composed of equal proportions of red,
used.
blue, and green color. At the time of white baianoe
calibration, the camera default melting is defined !or the Medical-grade liber optic ligfit cables consist of fiber glass
primary colors to equal proportions, assuming that the bund Jes, with a diameter between 3.6 mm and 6 mm, and a
target is white (Fig. 3B}. tength ranging from 180 cm to 350 cm (Fig. 38). For
general laparoscopy, a 5 mm diameter fiber optic light
in a aid light source an infrared filter or reflector is used to
cable with a length of 240 cm should be selected. These
remove the heat-producing infrared energy from the light
cables are made up of optical fiber bundles that are
beam before it is transmitted through the fiber optic light
swaged at both ends. The core is surrounded by a
cable. By re11ecting the infrared spectral range of the
cladding layer whlch allows the propagation of light by total
white light, the emission of thermal energy can be minimized
interns reflection. JTie outer diameter of a glass fiber, not
but not reduced to zero. Moreove, a certain degree of
that of The coating, is 125 pm. Fiber optic light cables are
the+mai energy is dissipated during light transmission
commonly used in laparoscopic procedures because of
along the fiber optic cable and the endoscope to which it is
their laugh-quality optical transmission
anr›ected. There are reports on accidents caused by fiber
properties, however th• >•i•r drawback oT glass fibers
optic light cables, that were inadvertently left on the drape
or on the patient's skin while the cold light source was stilt seems to be their relative kagilily. In fact, improper
switched on. it is therefore handling of fiber optic light cables can cause the libers to
crack over time.

Ftuid light cables are made up of a sheath filled with a

clear fluid (liquid—crystal gel). Theoretically, they are
capable of transmitting 30% more light than fiber optic light
cables. Owing to increased light efficacy and better color
temperature transmission, this type of cable is
recommended in those circumstances where special
emphasis is piacad on docu- mentation. The
disadvantages are that the quartz staging at the ends is
extremely fragile, and the fluid cables transmit more heat
arid are less flexible than the fiberoptic counter-

The durability of liber optic light cables is highly dependent

on proper maintenance. They should be handled carefully,
and twisting should be avoided. After completion of the
operation, the cable preferably sfiould be disconnected !
rom the endoscope and then again connected to the cold
light source. Most cold light sources currently available
have a special plug for holding the cable until it cools
down.
Manual of Gynecolog ical Laparoscopic Surgery
26 Manual of Gynecological Lagaoscopic Surgery

10.0 Forceps and Scissors

A set of ergonomic instruments that meet the anatomical
Atraumatic and grasping forceps are available in various
conditions and sp&sific requirements of the procedure is a
sizes and are indispensable for stabilizing tissues during
prerequisite o! laparoscopic surgery in gynecoiogy. in most surgery. Grasping forceps are available with single- or
laparoscopic procedures a combination of sharp and blunt double- action jaws. The single-action graspers are
dissection techniques is applied, ofien using the same preferred when the surgeon wants to work in a single
instru- ment in various ways. Most hand instruments can plane in a controlled manner, particularly during
easily be dismantled into three amponents: handle, adhesiolysis. Some handle types have connector pins for
insulaled outer tube and working insert {Fig. 40}. The insert unipolar high frequency cords and many have a
of dismantling hand instruments varies only at the distal mechanism for on-axis rotation of the working insert with
end. it may be a grasper, scisso+s, or forceps. Disposable the dish tip. Qhers have connectors that allow for suction
or reusable instru- ments may be used with diameters and irrigation, and sometimes a pistol grip handle with
ranging from 3 mm to 10 finger tñgger for cutting and ooagulatTon by use of high
mm. One atraumatic and two grasping forceps are usually frequency current (Figs. 41—42).
sufficient to perform the '''aior stees of surgical operations.
Manual of Gynecological Laparoscopic Surgery
Z6 Manual of Gynecological Laparoscopic Surgery

The protective insulation coating of the outer sheath of

laparoscopic instruments must be of good qualify to prevent
accidental electric bums to the bowel or oilier viscera. The
insulation may be a! nylon or heat-shrinkable plastic (e.g.,
fluropolymer or polyester). At the time of cleaning and
sterilization, suitable precautions must be taken to prevent
that the insulation coating of reusable laparoscopic instru-
ments is damaged due to improper handling or accidental
contact with any kind of sharp-edged material. Integrity of
the Insulation must be closely inspected prior to surgery to
make sure that even pinhole-sized defects in the insulation
of a laparoscopic instruments are detected. To make sure
that a laparoscopic instrument wth faully insulation cannot
go unrecognized despite close visual inspection under a
micro- scope, the preoperative use of an insulation testing
device as part of the routne workflow is highly
recommended.
Scissors and electrosurgical electrodes are the moor instru- Fig. 43
ments used for sharg dissection Tn laparoscopy. The proper GL1CKL1NE• scNors, etraJght
GLICKLINE° eoiesors, ourved (Metzenbaum)
use of scisso+s and electrosurgical instruments requires
that inexperienced surgeons-in-training have already
acquired an adequate level of technical proficiency before
performing sharp dissectioo on actual patTeots by means ol
lagaroscopy. There are various types of laparoscopic blades before they are closed. Hook scissors are
scissors. Scissors particularly useMi for transection of ducts, arteies or
wihslagh badesaewmmon@ uedlor iigarrients.
m‹xhniua dxwJo nIapaosoop«s @e Insulated scissors may also be used in unipoar electrosurgery.
admayMxbeuskio Closed blades may be used for blunt dissection and electro-
cut sutures. The most widely used scissors Tn cautery. When using nondisposable instruments, however,
laparoscopic surgery have a curved design. Slightly curved electrocoagulation with open blades can lead to blunting
blades offer the advantage of improved ergonomic of the blade edges. Adequate tension is usually applied to
handling by eliminating the need for a realignment of the the tissues to be dissected with the aid of a grasper in the
working angle of lagaro- sapic instruments. In addition, non-dominant hand while the other hand is performing
they allow for an improved endoscopic vision of the the cut. Given the proper use of insulated instruments, any
operating field (Fig. 43}. vessel encountered can be easily cagulated with the
The main advantage of scissors with serrated cutting edges grasper. The pitfall of this method is, that it requires
is that they prevent the tissue from slipping out a! the particular attention to be paid to the non-insulated distal
blades. Serrated scissors are particularly useful for cutting part of the scissors which accomodates the rnefal blades
slippery tissue and they may also be employed for culling and the hinge mechanism, an area which is prone to the
sutures. The blades of hook scissors can be partially closed potential risk of arc formation to non-target tissue. For safe
holding the tissue in the hollow-ground area without practice, this area must be kegt in view, howeve, at the
transecting it, thus allowing the tissue to be slightly retracted cost of a reduced magnification rar›ge available to tbe
before completing the cut. Moreover, this technical feature surgeon.
permits the surgeon to dooHJe-check and readjust the
position of the
28 Manual of Gynecological Laparoscopic Surgery Manual a! Gynecological Laparoscopic 'Surgery

11.0 High-Frequency Electroeurgery Techniques

There are various techniques of high-frequency electro-
surgery, i.e.. the way the elec trical cui rent is applied to the While cleavage of tissue layers is obtained mostly with the
tissue. Traditionally, high-frequency electrical current can be unipolar technique, coagulation can be accomplished by
applied in two ways: unipolar or bioolar.

11.1 Unipolar Electrosurgery

The unipolar technique is the most common ly applied

method due to its versatility and clinical effect iveness. However, the new generators great ly reduce the risk of
in unipol ar electrosurgery, the active electrode is at the electrical in|ury. Unipolai electrosurgery may be applied for
surgical site. The patient return elec trode (grounding pad) coagulation, !or pure sec tion, and coagulation—section by
is elsewhere on the pat lent’s body. The current passes use of the blended (mixed) cui rent. The coagutat we current
through the patient as it completes the circuit from the active is characterized by intermittent periods of electrical activity
electrode to the patient return electrode. Unipolar electricity during which cellular dehydration and protein coagulation
is potentially dangerous because part of the path traveled are evoked which finally induces hemostasis. The non—
by the electrons is unknown. As a result, there is a ootent ial modulated cutting current is a continuous flow of electrons
risk Of electrical burns at a distance !rom the active eiec that causes a rapid rise in intracellular temperature resuhing
trade. in an explosion of the cell. We suggest always to use the
continuous current

Uni polar needle electrode.

for coagulation because the voltage is lower. This applicot

ion mode is less dangerous and can be as effect we as pure blunt-tipped electrode. Unipolar hooks are also available in
coagulation or blended coagulation-section current. various shapes with L-, J- or U-configuration. In addition,
The surgeon can choose among vanous shapes of uniool ar ball-shaped, barrel-shaged or straight coagulation
electrodes accords ng to the indication and inddvidual electrodes may also be used to achieve proper hemoslasis.
preferences (Figs. 44a, b). The spatula- and hook-shaped Blunt-tipped electrodes are particularly useful in the event of
electrod es are mainly used for unipol ar c utting and diflusely oozing hemorrhage if the point of bleeding cannot
coagulat lan. the spatula either comes as W-shaped or be clearly localized. Besides, the blunt—tipped electrode
may also be used for blunt dissection during endometrial
ablation.
Manual of Gynecolog ical Laparoscopic Surgery 29

11.2 Bipolar Electroaurgery

In the bioolar system. the current flows from one jaw of the
there is an obvious risk of patient burns if the thermal effect
bipolar forceps (the first electrode) through the tissue to the
spreads further than desired. For this reason, the energy
other jaw (the second electrode). The flow Of the electro-
should always be applied with short exposure times and at
surgical current in the patient is restricted to a small volume
an adequate distance front vulnerable structures. This basic
of tissue in the immediate area of application. This affords
rule not only applies to the proper coagulation of vessels but
improved control over the area to be treated. latrogenic
must be followed in all laparoscopic procedures. Disposable
injury to vulnerable structures in close proximity to the
and reusable bipolar forceps of vsious sizes and shapes are
electrodes can be avoided. The risk of cut rent arcing, direct
available (Fig. 45}. In gynecological surgery, bipolar forceps
coupling, and capacit we coupling is very low, which is why
patient burns are virtually eliminated. Bo'^ iaws of the requires precise and limited coaguiat ion, or when the surgeon
bipolar forceps are insulated, accordingly there is no need wishes to reduce the extent of the thermal effect, 1.5 mm-
for aftaching a patlenI return electrode. Since coagulation is iaws stnould be used. in this case, the power density will be
eflec ted by a steep increase of the temperature in ttne elevated, tnovzever, exposure time is limited.
tissues, however,

Fig. 46 ” ‘
Fig. 4'2 RoBP Bipoler Grasping For¢eps end Sciss or—d
Close-up view oT the tips of bipolar forceps. Clermont-Fermr›d type (KARL STORZ Tuftlingen, GemJany).

This new series of sop filstic at ed bipolar instr u ments with

The efforts of current reseai ch and development have rot afional and exchangeable working inserts significant Iy
shown an increasing tendency toward the use of bipolar ! contr ibu tes to ergononJ ie efficiency and wortrflow in the
orceos with added functionality such as grasping, dissection ocerat ing room. For mantenance and sterilization the
and cutting. The m•'• •^i•°'i•• is to reduce the number of instru- ment can be easily disassembled. In summary, the
instrument changes required during surgery. The new authors prefer to use the RoBi* bipolar gi asping forceps
rotational bioolar instnuments (RoBi* bipolar grasping and scissors as first-choice option, in alt other cases
forceps and scissors— Clermont Ferand type) meet the conventional bipolar instrument or a Kepplinger spatula may
reouirements of four basic actions of surgery: dissection. be used, the latter creating a large zone of coagulat ion.
cutting, grasping and hemo- stnsis (Fig. 46). The wailing
inserts can be swiftly exchanged during the operation
according to the needs of the surgeon.
30 Manual of Gynecological Laparoscopic
Surgery

12.0 High Frequency

Electrosurgical Units
The AUTOCON" II 400 is a versatile, state-of-the-art
high frequency electrosurgical unit designed for both
unipolar and bipolar electrosurgical applications. The
operational parameters of various cutting and coagulation
settings can be preselected on the frontpanel display,
thus providing the user with a highly accurate and
reproducible method to obtain good results. Exact fine-
tuning in 1 W-steps is enabled for procedures that
require maximum precision at very low power. Up to 8
hemostatic effects for unipolar and bipolar cutting, each
with up to 370 W output, permit optimal control of
coagulation and the intended surgical effect. In the
bipolar coagulation mode, the autostart function auto-
Fig. 47 matically activates the coagulation current as soon as
The high frequency electrosurgical unit AUTOCON* II 400, the electrode has touched the tissue with both branches.
(KARL STORZ Tuttlingen, Germany).
The various safety circuits of the unit provide a very high
level of safety for both the patient and staff. Software-
supported test programs ensure easy and rapid servicing.
The color touch- screen with its modern and user-friendly
design allows for easy operability, maintenance and
cleaning (Fig. 47}.

13.0 Laser Systems

The most commonly used type of laser is the CO laser,
which is also considered to be the most precise which
causes the least thermal injury. Even though the CO, laser is impact on the outcome of the laser treatment, such as
considered to be highly efficient in terms of tissue the inherent absorption characteristics / wavelength of the
vaporization, cutting or excision, but has only minimal laser system specifically selected for the intended application,
coagulating properties. Lasers with a short wavelength such spot size, power density, mode of delivery (contact/ no
as Argon, Neodymium:Yttrium- Aluminum Garnet (Nd:YAG) contact) and exposure time (intermittent or continuous).
and KTP 532 lasers (Potassium Titanyl Phosphate;
KTiOPO„ KTP) have good coagulating properties but are In summary, each of the various laser systems available
less efficient in terms of vaporization. The degree and on the market has a specific clinical application. Laser
extent of thermal damage produced by laser irradiation generators are much more expensive than electrosurgical
depends on the structure, water content, pigmen- tation systems, and there are many safety aspects, such as the
and the state of tissue perfusion. In addition, user- potential risk of cumulative thermal effects, burns due to
determined operational parameters can have a considerable inappropriate expo- sure and retinal damage, that speak
against the widespread use of laser technology.

14.0 Ultrasonic Dissection and Coagulation Systems

The use of ultrasonic energy for cutting and coagulation is an in liver surgery). High power settings can be applied to
cleave alternative to electrosurgery. Ultrasound is the unique energy the loose surrounding tissues by frictional heat
while simulta- form that allows both cutting and coagulation of tissues neously coagulating the wound margins
(frequently applied in without exposing the patient to the risks associated with the colon surgery). High-power
ultrasonic dissection can cause application of high frequency current. The major benefit of collateral damage by
excessive generation of heat. However, this alternative technique is that only a minor degree of lateral in view of the
high level of operational reliability and safety heat-induced tissue damage occurs. Ultrasonic systems that feasible
with this alternative technology, the anticipated are operated at low power settings cleave water-containing
advances in the further development will certainly make it a tissues through cavitation sparing organized structures of
low valuable tool in the future.
water content without coagulating vessels (frequently applied
Manuat of Gynecolog ical Laparoscopic Surgery 31

15.0 Suction and Irrigation Systems

Controlled suction and irrigation is of great import ance
because it provi¢les the surgeon with a clear field of vision
during laparoscopic st irgery. For that reason, we suggest
to have a suction-iri igatiOn system on stand -by even in
cases of cllagnostic laparoscopy (Fig. 48). The system may
also be used for lavage of the abdominal cavity, control of
bleeding and aspiration of clots, as required by the
individual situation. The electronJotor-driven pi essureYsuct
ion pump is protected against entry of body secretions. Hy
drodissect ion
wikahgCg srewawstev judo-p)oi io200
mnJHg may also be applied lor cleavage of tissue layers
and spaces Most surgeons use physiological saline or
Ringer’s lactate solution for irrigation purposes. At times,
hepai inized saline is used to dissolve blood clots and
facililate adequate aspiration in cases aI profuse intra-
abclominal bleeding. A 10 mm—suction cannula should be
used in the presence of tnore than 1500 ml of
hemoperitoneum oi if there are blood clots inside lhe
abdoirinal cavity. Auction-irrigation cannulas are available in Deming laparoscopic surgery, suction-irrigation cannulas may
vai ious sizes ance tnust be selected according to the trocar be used for aspii ation of fluid contents of ovarian cysts, bile
size of the laparoscopic appi oach. or for injection of vasoconstrict we agenIs. Gai eful attention
Aspiration needles or suition cannulas have a standard size musl be paid during insertion a f the suction cannut a to
of 5 ion (Fig. 49) fitted for being inserted through an acces- prevent inadvertent pet foration of viscera.
sory G nJnJ-ti ocar (Fig. 50)

5 mm-suction cannula (top): 10 mm-suction cannula with

ergonomic pistol handle (bottom).
Distal tips of cue tion cannula (top) and puncture needle tbotlom).
32 Manual of Gynecological Laparoscopic Surgery

16.0 Suture Techniques

Advanced laparoscopic procedures can be performed
safely and effectively only if the surgeon or gynecologist
has gone through the initial stages of surgical training and
has gained an adequate level of proficiency in intracorporeal
suturing and knot tying techniques. Laparoscopic suturing
and knot tying should be practiced on a good quality
endotrainer with an experienced tutor. There are two
suturing methods: the intra- corporeal and the
extracorporeal technique. The major steps of the
intracorporeal technique are: introduction of the needle and
intraabdominal suturing, placement of suture ligatures,
knot tying, either extracorporeal or intracorporeal.
Intracorporeal suturing techniques involve that each knot
is formed and tied inside the cavity with the aid of needle
Fig. 51 holders. There are many different types of needle holders
The SZABO-BERCI Needle Holder PARROT-JAN with straight that essentially vary in handle design and tip configuration
handle and adjustable ratchet. (Figs. 51—52). In our opinion, intracorporeal knots should
be reserved to experienced surgeons, because advanced
procedures require a good command of microsurgical
suture techniques. Once an adequate level of proficiency in
intracor- poreal suture and ligature has been achieved, the
surgeon's conversion rate will certainly decrease.

a b
Fig. 52a Fig. 52b
Various needle holders with curved jaws. The KOH Macro Needle Holder with curved jaws, ergonomic
pistol handle and disengageable ratchet.
Manual of Gynecological Laparoscopic 33
Surgery

As the term denotes, extracorporeal suturing and knot

tying is performed outside the body cavity. Once the
tissue is sutured, the needle is removed through the
trocar cannula and the suture is completed
extracorporeally. In this case, a knot tier is required. Even
though pre-tied loops are available in the market,
surgeons-in-training should learn the basic skills of
extracorporeal knot tying. For extracorporealknotting various
types of knot pushers can be used. Knot pushers are of
either closed-jaw or of open-jaw type (Fig. 53). For a
trainee who has strong convictions to pursue a surgical
career it is essential to make every effort to perfect
his/her skills to achieve an adequate level of proficiency
in suturing techniques. The correct extracorporeal Roeder
knot is very useful. For major or safety sutures, e.g., for
ligature of a uterine vascular pedicle in hysterectomy, the
extracorporeal Roeder knot is necessary. To push the knot, a
specific open-jaw knot pusher is used. The endoloop is the Fig. 53
oldest device used for laparoscopic-guided ligature; it is a Knot tier for extracorporeal knotting. The close-up views show
loop with a pre-formed slipknot that can be positioned the various types of open-end, and closed-end tip design.
around the structure that needs to be removed.
In some cases, a laparoscopic clip applicator may be neces-
sary. In minimally invasive surgery, surgical clips are used for
tissue approximation. Most of them are made of pure titanium
or of titanium alloys. Surgical clips are easy to apply and
can be left inside the abdominal cavity. After a few
weeks, the clip is covered by fibrous tissue. The jaw of
the clip appli- cator should be located perpendicular to
the wound site before deploying the clip, the surgeon
should take care that both jaws are in view. Two clips are
usually deployed over the structure that needs to be
secured. One clip is deployed over the tissue which the
surgeon wants to remove to prevent spillage of fluid. The
clips should not be applied very close to each other.

17.0 Extraction Bag

Disposable extraction bags are very important to
prevent contamination of the abdominal wall during
extraction of specimens from the abdominal cavity (Fig.
54). Extraction protected by an endoscopic bag is
mandatory to obviate the risk of benign dissemination (e.g.,
in the case of endometriosis, ectopic pregnancy, and benign
ovarian cysts), spillage during removal of a benign
teratoma, risks of infection (pyosalpinx), and risks of
malignant dissemination (suspected cysts). The extraction
bag must be very strong so that it can resist the force
that is exerted by the surgeon while pulling it through a
small opening.

Fig. 54
Disposable extraction bag.
34 Manual of Gynecological Laparoscopic
Surgery

18.0 Morcellator Systems

An electronic or manual morcellator can be used for The removal of large portions of tissue may also be
piecemeal removal of large specimens, such as fibroids or the accom- plished with the aid of endoscopic cold knives
uterus during laparoscopic hysterectomy, and particularly, introduced through a minimal abdominal incision or
supracervical hysterectomy (Figs. 55a, b). The fully vaginal puncture. These shielded blade carriers permit
autoclavable ROTOCUT G1 morcellator is an efficient endoscopic insertion and application of cold knives in the
and time-saving alternative to previous systems. Rapid abdominal cavity. There is a great variety of extraction
removal of large tissue segments is facilitated by the devices on the market. One, that should be mentioned is
highly efficient cutting performance of the disposable the vaginal extractor. It allows intra-abdominal
cutting blades, which can be changed intraoperatively. specimens to be retrieved via the vagina, while
The blades are available in sizes of 12-mm or 15-mm. maintaining the integrity of the pneumoperitoneum and,
Optimal weight distribution and direct activation ensure a therefore, endoscopic-assisted retrieval under optimal
straight-forward and smooth operation. A specially viewing conditions. During laparoscopic myomectomy, it is
designed trocar sleeve protects tissue from inadvertent essential to have a screw- or spiral-tipped instrument
blade contact. The powerful ROTOCUT G1 has a direct that allows for proper fixation and removal of subserous or
drive motor that produces a maximum speed of 1200 intra- mural fibroids (Fig. 56).
rpm, minimizing the amount of effort required of
surgeons and reducing procedure times. The control
unit that optimizes Rotocut's performance is the
UNIDRIVE^ S III, which is compatible with all previous
generations of KARL STORZ morcellators.

Fig. 55 a
Fig. 55 b
The morcellator system ROTOCUT G1, laparoscopy set.
The hollow shaft motor of the ROTOCUT G1 mocellator is used in
conjunction with the control unit UNIDRIVE^ S III.

Fig. 56
Myoma fixation instrument with screw-shaped tip.
Manual of Gynecological Laparoscopic 35
Surgery

19.0 Uterine Manipulators

Various instruments and auxiliary devices may be used for diagnostic assessment or surgical interventions. The uterine
mobilizing or stabilizing the uterus and adnexae during both manipulator is of crucial importance because it facilitates
diagnostic and operative laparoscopic surgery. visualization of the pelvic organs and permits endoscopically-
A uterine manipulator is used in the majority of advanced controlled injection of methylene blue in the case of chromo-
laparoscopic-assisted gynecological procedures, be it for pertubation for assessment of tubal patency (Figs. 57—59).

Fig. 57
The TINTARA uterine manipulator (KARL STORZ Tuttlingen, Fig. 58
Germany). Proper placement of the uterine manipulator.

Fig. 59
The CLERMONT-FERRAND uterine manipulator
(KARL STORZ Tuttlingen, Germany).
36 Manual of Gynecological Laparoscopic
Surgery

20.0 Operating Room Setup and Preparation of the Patient

Endoscopic surgery requires a perfect technologic environ- Patients must be informed of the therapeutic benefits
and ment. Knowledge of the instruments and operating room all potential risks (informed consent). The possibility
that setup is essential for optimizing the workflow of endoscopic a laparotomy may be required must always be
mentioned. procedures and the facilitating the interaction between Intestinal preparation is often useful. Bowel
preparation can surgeons, medical personnel, and all areas inside and outside minimize the need for an accessory port
to retract the bowel. of the hospital. A well organized operating room is not only Its purpose is to empty the small
intestine and facilitate vision an essential prerequisite for the successful outcome of Iapa- by flattening the intestinal
loops and pushing them out of the roscopy, but also reduces costs. The operating room should way. In all cases
associated with an increased inherent risk of be large enough to accommodate the necessary equipment. intestinal
injury is (endometriosis of the rectovaginal septum or Before starting surgery, it is necessary to check the instru- major
adhesiolysis), preoperative bowel preparation is more mentation, particularly the insufflation unit, as well as the
complete and resembles the preparatory measures applied high frequency surgery unit and the suction-irrigation
system. prior to bowel surgery. Before being admitted to the operating The number of persons forming the surgical
team depends room, the patient should always void. The full urinary bladder on the surgical indication. As a rule, one
assistant and one may be inadvertantly perforated during insertion of the Veress surgical nurse are sufficient. Certain
procedures require an needle or trocar. If gynecological surgery or any gener additional assistant (Fig. 60). It is
essential that all members lower abdominal surgery is planned (such as hernia repair or of the surgical team
(including the surgeon) be trained and adhesiolysis) it is advisable to insert a Foley catheter. If any capable of
solving all technical problems which could occur upper abdominal procedure has been scheduled, it is good before
and during the intervention. practice to have a nasogastric tube in place.

Fig. 60
Schematic drawing of the room setup illustrating the optimal arrangement of the surgical team and equipment during gynecological
laparoscopic procedures. @ — operating surgeon; @ — first assistant; @ — second assistant; @ — scrub nurse; @ —anaesthesiologist.
Manual of Gynecological Laparoscopic 37
Surgery

21.0 Patient Positioning

Positioning of the patient is also important for the The assistant seated between the legs of the patient watches
successfu outcome of surgery. The patient is placed in a the hand movements of the surgeon on the monitor and
low dorso- lithotomic position (gynecological position) should maintain traction in the appropriate direction with
with her legs positioned to provide vaginal access (Fig. the handle of the uterine manipulator.
61). The patient's legs should be comfortably supported
by padded obstetric knee braces or Allen stirrups to
Proper make-up assignement of the surgical team is also
minimize the risk of deep vein thrombosis (Fig. 62). The
a basic prerequisite for the successful outcome of any
Trendelenburg position should be used only after the main
laparo- scopic operation. In the majority of cases, the surgeon
trocar has been inserted, because the Trendelenburg
stands on the left side of the patient. A surgeon who is left
position brings the sacral promontory, and therefore the
handed, should stand to the right of the patient during
major vessels (bifurcation of the aorta and left common
creation of the primary port. This facilitates inserting the
iliac vein) into the axis of trocar insertion. In gyneco- logical
Veress nee- dle or primary trocar towards the pelvis with
laparoscopic procedures or if laparoscopy is to be
the dominant hand. The camera assistant should be
performed together with hysteroscopy, the patient should
positioned opposite to the surgeon, but it is always
be positioned in the lithotomy position which enables an
recommended to have two video monitors, one for the
assis- tant to stand between the patient's legs allowing
surgeon, and one for the camera assistant and other
for free access to the lower abdomen (Fig. 63). In these
members of the surgical team. If only one monitor is
procedures, the surgeon needs to use a uterine
available, it should be located between the legs of the
manipulator for proper visu ization of the female
patient.
reproductive organs.

Fig. 61
Correct preoperative placement of the patient on the operating table
in low dorsolithotomic position.

Fig. 63
Placement of the patient in low dorsolithotomic
position enables proper manipulation of the
laparoscopic instruments via the accessory ports.

Fig. 62
The legs are gently placed in well-padded boot-type stirrups for
routine deep vein thrombosis prophylaxis.
38 Manual of Gynecological Laparoscopic
Surgery

22.0 Maintenance and Sterilization

Professionals in charge of cleaning, decontamination, sterili- Disposable instruments are not designed to be cleaned in
zation, and inspection of surgical instruments, devices, a similar way as their reusable counterparts, e.g., the
and implants should be adequately trained so that they CLlCIf‘/ine series of dismantling instruments. Reusable
are fully aware of the delicacy and cost of endoscopic surgical instru- ments must be safely cleaned and sterilized
equipment. Setting up the operating room prior to immediately after surgery. Instruments must be dismantled
surgery includes testing the camera equipment, the light prior to cleaning. After decontamination, every small piece
source, the insufflation unit and CO2 tanks, the suction- and recess must be cleaned and dried with water and
irrigation system and — taking great care — the bipolar compressed air. For lenses and telescopes, alcohol or special
and unipolar electro- coagulation system. soap should be used. The majority of up-to-date
Because of the importance of having optimized instruments are designed for steam heat sterilization
instrument management quality and economy, KARL (autoclaving). Other validated sterilization procedures
STORZ has developed the EndoProtect1 "service, currently in use:
consisting of modular services that ensure the optimal • Sterilization via autoclave is the most widely used
deployment of instruments sets in the hospital, the and inexpensive method. In the case of endoscopes and
replacement of instruments and their proper and careful instru- ments expressly manufactured and sold as
handling by personnel. Also a database- supported autoclavable, sterilization cycles of 121°C for 20
management and monitoring system is offered for the minutes, or 134°C for 7 minutes are used.
entire range of instruments in offices and hospitals. This
new system is the KARL STORZ instrument manage- • Gas sterilization with ethylene oxide is generally considered
ment platform, which enables each individual instrument to be the ideal method of sterilization, because it acts at
to be accurately registered using a special data matrix code a relatively low temperature and is not detrimental to
and rapid, error-free identification with a scan camera. endo- scopic instrumentation. Unfortunately, the
technique is relatively expensive and time-consuming
Disposable instruments shall not be resterilized for reuse in (72 hours prior to reuse of instruments). Therefore, only a
laparoscopic surgery because such practice is few centers use gas sterilization, because multiple sets
associated with an elevated risk of pathogen of laparoscopic instruments should always be held
transmission compared to the effectiveness of cleaning available.
and sterilization procedures applied to reusable
instruments.

Recommended Literature:
MENCAGLIA L, WATTIEZ A: Manual of Gynaecological
Laparoscopic Surgery. (2000); Endo-Press° Tuttlingen,
Germany
HULKA J, REICH H: Textbook of laparoscopy,
Third edition (USA). (2002); 53—56, 69—81, 276—283