Welcome to our Basic Skills for the OR Series!
Complete series includes:
I'm Brandon Buckner, and this is the Surgical Tech Lab at Lamar State College Port Arthur in Port Arthur, Texas. Today we're going to look at laparoscopic instruments. We're not in a sterile environment. We're in our lab. We want to look at the individual instruments and what they're used to accomplish - how we put them together, and how we take them apart, and how we use them.
What we have is a basic laparoscopy kit, and it may be different than what you use in your home facility. Remember, each facility will have its own surgical instruments. The old laparoscopic instruments were solid where the newer ones tend to be in multiple parts because it's easier to take apart and clean. Some instruments change at the tip, some have interchangeable inserts. The ones we have have insert sleeves and handles that are all interchangeable. So remember to follow your institution's policy and procedures for cleaning, manipulating, and packaging.
So the laparoscopic instruments that we use in this area come from the Karl Storz company. They come in a variety of lengths and sizes. They usually come with three sections.
The first section is the insert. The insert that we have on the Mayo stand, is a right angle for doing laparoscopic cholecystectomy and laparoscopic appendectomy.
The insert gets picked up and placed through a black metallic sheath. Once the insert is seated fully into the black cover, we will turn it and make sure that it stays in its place.
We will then add the handle. The handle slides on and locks in place, and you'll hear it click. Once it is seated in completely, we can open and close to make sure that the instrument is functioning properly. Also, there is a channel to push through. We want to make sure that the cap for that channel gets plugged up so that we don't lose carbon dioxide gas when we introduce this instrument into the pneumoperitoneal space. Also, you'll notice that at the end of the handle is a metallic wand that our Bovie cord is going to sit on. If we wanted to, we could electrify the end of this instrument - grab a bleeder, and use our foot pedal to activate it, and cauterize a small bleeder.
To remove this - after it's used, blood often gets into the inside of these things and we know that if we're going to decontaminate something, anything that gets put together has to be taken apart. To do so, we press the button on the handle, and the handle will slide right off. We will twist the insert, and slide the sheath off of it, and this is - after we spray it down with enzymatic cleaner - this is how we will return our instruments to the work room.
Usually our instruments are going to fall into different categories. We'll have dissectors. Dissectors are the instruments that our surgeons are going to use to separate blood vessels and ducts. There's three that our guys use the most: the dolphin nose, which comes to a dolphin nose point, the Maryland, and of course the laparoscopic right angle. Each one of these is going to be used on a handle without a locking mechanism. Scissors, dissectors - we don't want those instruments to lock. We want to use them in a way that they're able to open and close freely without locking in place while the surgeon's using it.
To assemble - once again, we take our insert and slide the sheath over it. Once the insert is fully seated, we twist it and we add our handle. We'll feel it lock into place and we will open and close to assess for function. If we need to, our surgeon can rotate these instruments using his index finger to rotate while they're inside the abdomen.
If our surgeon likes a more pointed dissection tool, we have the Maryland. The Maryland dissector we'll approach the same way. The insert will slide down the black sheath. Once we get it seated completely in, we'll twist it and we'll attach our handle. This one did not have the plug for the access port, but we can take it from another instrument and put it on. The Maryland is a much finer dissector that we can get in between and have a longer limb on our tool.
The dolphin nose dissector we'll apply the same way. The insert goes down into the sheath, we twist it once it's completely seated, open up our handle, slide it on, and you'll hear the click. Once the click is heard, we can open and close the tip and ensure that we're handing our surgeon a functional and working instrument. To disassemble, we'll press the button on the handle. Slides right off. Twist the insert away from the sheath, and they separate.
These will be flushed, wiped down with enzymatic cleaner or spray cleaner - some places use the expandable foam - and we're going to decontaminate our instruments in the OR before we send them to the dirty side of the work room.
Earlier, we looked at dissectors like the Maryland, the dolphin nose, and the right angle. When you use a dissecting instrument, you want to make sure that the handle doesn't lock. Our surgeon needs to be able to open it and close it without it locking in place and him having to maneuver it. When we use a grasping instrument - the grasping instruments are where we want to hold our locking handles on. So that - say we're doing a gallbladder and we need to invert the gallbladder and look at the underside of the liver, we want to be able to lock that instrument on and make sure it maintains his grasp the whole time.
On the Mayo stand, we have a few versions of different graspers. The first grasper is vascular in nature. It has the same jaw pattern as Debakey forceps or a vascular clamp. Just like the other instruments, the insert goes down the inside of the sheath. Once we get the insert completely seated, we give it a little twist, and now we're going to put on a locking handle. The locking handle, opened fully and inserted, you'll hear it lock, and we'll test it to make sure that our instrument is working properly.
Now with the flick of a wrist, I can lock this instrument in place, and you'll hear it ratchet down. Once we're here, I can let go, and the grasper is still attached. To release it, we'll pull down on the trigger, and it will open again. To take this instrument apart, we depress the button on the handle, separate the handle, twist the insert, and pull it out of the sleeve.
There are a variety of different graspers. Some traumatic with teeth, others smooth. It's your surgeon's preference over which one he uses, but they all assemble the same way.
The insert goes down the center of the sheath, we seat the insert all the way in, and give it a twist. This locking instrument has a ratchet on the bottom. We'll open it fully, slide it into the instrument, and we hear it click. Once we're seated completely and connected, we open and close it to make sure it's working properly. Once our surgeon uses his pinky finger to slide this piece down, there's our ratchet. When he's ready to close on a piece of anatomy, it'll ratchet closed, and once he lets go, it stays in the closed position. Once again, to remove the handle, we'll open the ratchet, push down on the button and it slides right off. Now we take the insert, twist it, separate the insert from the sheath.
Our last instrument is an atraumatic grasper. Just like the first one, this doesn't have a lot of teeth on it so we don't puncture holes in anything. We're going to slide the insert down the sheath, seat it completely, and twist it, and this time some surgeons may want a non-locking handle, and that's okay. They still click on. This time, this instrument, although it's a grasper, it won't stay in a locking position, and it will be up to your surgeon as to whether he wants it locking or non-locking. We test it before we hand it to the surgeon to make sure it opens and closes. And just like the others, to remove the handle, we press down on the button, it slides right off, twist the insert, take it out of the sheath.
All of these instruments are going to get wiped down and sprayed down with enzymatic cleaner before we return them to the dirty side of the instrument room.
So laparoscopic instruments have the ability to add the Bovie to the instrument. We'll take the insert and place it down the sheath, seat it completely, and give it a twist. When we put our handle on, the handle has a male connector for the female connector on the Bovie cord. Once connected, the surgeon can introduce the laparoscopic instrument inside the abdomen, grab an individual bleeder, and with the foot pedal can activate the instrument and cauterize the bleeder from the inside without the need of opening up the patient. Once used, the surgeon can disconnect the Bovie cord, place it back into the pouch, and return the instrument to the Mayo stand.