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Laparoscopic technologies: an inside look.

Perhaps the greatest advancement of the last quarter century, relating to the way surgery is performed, is the advent and subsequent development and growth of laparoscopic surgery. While laparoscopy, a minimally invasive approach to traditional open abdominal surgery, was reportedly first used in 1901 by Russian gynecologists, it was not until the mid-1970s that it began to receive significant attention. Used primarily during this time for diagnostic and observational purposes in gynecology and oncology, the late 1980s saw laparoscopy flourish into an effective tool for not just diagnostics, but "also treatment for a variety of abdominal ailments.

An Alternative to Open Surgery

Laparoscopy is a surgical procedure that allows the surgeon visual and physical access to a patient's abdominal cavity without the large incision that opens the abdomen in traditional laparotomy. During a standard laparoscopic procedure, a hollow needle is inserted into the abdomen of an anesthetized patient and carbon dioxide is pumped in, expanding the abdomen. A small incision is then made in or near the navel and a laparoscope, a slender viewing robe affixed with a small camera, is inserted into the abdomen. The laparoscope camera is connected to a video monitor on which the surgeon can view the interior of the abdomen or pelvic cavity. Other small incisions are also made in the abdomen to allow access for laparoscopic instrumentation that can be used to lift and position organs or perform surgical procedures.

Due to the minimally invasive nature of laparoscopy, the after effects for a laparoscopic procedure are much less severe than in open surgery. Patients report feeling less pain, and there is less scarring and risk of infection. Recovery times are also significantly reduced, with patients being able to return home just a few hours after the surgery, as opposed to the several days of hospitalization required following traditional abdominal surgery.

These improved post-operative results have helped to push laparoscopy well beyond the bounds of its initial indications. Over the past two decades laparoscopic approaches to areas outside of just gynecology and diagnostic oncology have been consistently increasing. Currently, there are few abdominal procedures that cannot be performed laparoscopically. Laparoscopic approaches to appendectomies, cholecystectomies, nephrectomies, hernia repairs, and a variety of bariatric and gastric surgeries have all proven effective. While open abdominal surgery may never truly become obsolete, what with certain circumstances and potential complications making laparoscopy difficult or impossible in some cases, ever increasing laparoscopic technology is destined to make it an even rarer necessity.

Traditional Tools of the Trade

While the negative after effects of abdominal surgery have decreased thanks to the laparoscopy, the instrumentation, equipment, and technology required to perform the procedures has increased and become more advanced. Laparoscopic procedures require a special set of tools to facilitate and accommodate access to the surgical site, visualization of the surgical site, and maneuvering within the surgical site.

Access to the surgical sites in laparoscopy, as previously mentioned, is provided through small incisions in the abdomen, usually measuring no more than a half-inch. These small incisions permit the introduction of a trocar, which functions as an access port for the laparoscopes and laparoscopic instruments.

The traditional laparoscope is a slender, rigid, tubular endoscope containing relay lenses that project an image of the interior of the abdomen to a small camera located on the eyepiece of the laparoscope. The camera then displays these pictures onto a video screen, providing the surgeon with a view of the surgical site. To provide this picture though, a light is needed to illuminate the abdominal cavity, and an insufflator is necessary to expand the abdomen, allowing room for the laparoscope and any other required instruments.

The instruments that were initially developed to accommodate laparoscopic surgery were essentially longer versions of traditional instruments. Forceps and scissor tips, as well as cutting and coagulating electrodes are attached to long thin shafts so that they can be inserted into the abdomen through trocars. Handles at the exterior ends of the shafts permit the surgeon to maneuver and control the instruments inside the body.

Naturally, the advancements and tools that brought laparoscopy to its present prominence are still being widely and effectively used today. There have, however, been a number of further advancements in laparoscopy technology in the past few years that have made laparoscopic procedures easier for the surgeon and easier on the patient, and may well change the way the procedures are performed in the futures.

New Technologies

Some of the problems inherent with traditional laparoscopes are fogging between the lenses during a procedure and image distortion or deterioration following disassembly, cleaning, and reprocessing of the scope. Olympus has developed a system to address these problems by taking the laparoscope entirely out of the laparoscopic procedure and replacing it with a single-component, autoclavable videoscope. Matt Fahy, Director of Marketing-Olympus Surgical explains, "What Olympus has uniquely been able to do is eliminate the entire multi-component system: the laparoscope, the light cord, the camera, the camera adapter, and the camera coupler. Instead, with our EndoEYE surgical videoscopes, we put the camera inside the body."

EndoEYE[TM] videoscopes utilize a color CCD miniaturized camera chip that is located at the distal end of the scope, placing the camera directly at the surgical site. Available in 10-mm and 5-mm versions, and in both straight viewing and 30-degree angled viewing configurations, these videoscopes can meet the needs of virtually any laparoscopic procedure for a wide range of surgical specialties including general surgery, ENT, urology, gynecology, colorectal, bariatric, and more. In addition, included in the EndoEYE family is a truly unique development in laparoscopic technology. The LTF-V3 laparo-thoracic surgical videoscope features a deflectable tip that allows four-way angulation. This provides the surgeon with unprecedented maneuverability and anatomical viewing capability.

All of the many varieties and configurations of EndoEYE videoscopes are powered by Olympus's VISERA[TM] digital imaging platform, which is designed to meet surgeon demands for high performance and cross-specialty utilization. John Cifarelfi, General Manager & Vice President-Olympus Surgical describes the advantages of the system. "All of the rigid EndoEYEs, the deflectable tip, and the different flexible models for all of the multiple surgical applications work off the same imaging platform, which is called VISERA. So VISERA is truly a multi-specialty imaging platform for the OR. It certainly enables standardization from room to room, and makes training of the support staff that much easier because it's just one system to learn, and each EndoEYE is specialized for its unique properties."

"From our point of view," adds Matt Fahy, "If we can help the customer do more procedures with less equipment, that's advantageous for everyone."

New Instrumentation

Cardinal Health has long been a provider of traditional and laparoscopic instruments with its extensive V. Mueller line, but has recently expanded its offering by acquiring Snowden Pencer. The V. Mueller and Snowden Pencer fines of reusable laparoscopic instruments are designed to meet the functionality demanded by surgeons while still taking into account the cost sensitive nature of the managed health care environment. The Snowden Pencer line recently introduced a series of ergonomically designed instruments that were developed with surgeon comfort in mind. Sean Looney, Marketing Manager for Snowden Pencer Laparoscopy Products describes the new offering. "Specific to the Snowden Pencer line are the Diamond-Touch, Diamond-Drive, and Diamond-Flex products, ergonomically designed to uniquely meet the needs of surgeons performing advanced laparoscopic procedures including Nissen Fundoplications and Bariatric surgery. Additionally, our Switch-Blade resposable laparoscopic scissor solution allows hospitals to save significant costs by not having to purchase disposable laparoscopic scissors."

The Diamond-Touch products are in-line ergonomic laparoscopic instruments that help surgeons to retract and access critical structures. The Diamond-Flex line includes articulating retractors and graspers for advanced laparoscopic procedures, while the Diamond-Drive fine is comprised of pistol-grip style laparoscopic instrumentation that delivers fine dexterity of movement. Though relatively new to the market, these product fines are already gaining popularity thanks to the elimination of the traditional ring handles that can cause discomfort in long procedure.

"The Diamond Drive line was launched just this year and has been very popular on needle holders," says Looney. "Many of the advanced lap centers around the US (MCV, UPMC, UC Irvine) use the Diamond Touch products almost exclusively."

The Auto Suture division of US Surgical, a leader in wound closure products, offers a laparoscopic instrument that facilitates intracorporeal suturing, delivering running or interrupted sutures of varying sizes. The ENDO STITCH[TM] Device is designed to use both absorbable and non-absorbable sutures and has a definite value in laparoscopy. Scott Herring, Group Director, Auto Suture Marketing for US Surgical claims, "Many surgeons suggest that ENDO STITCH Device can assist with complications that can arise during laparoscopic surgery, potentially preventing the need to convert to an open procedure."

Auto Suture also provides hands-on workshops led by certified surgical specialists, as well as training and instructional videos for those interested in the ENDO STITCH specifically and minimally invasive surgery in general.

While many new technologies that are being developed for laparoscopy concern themselves with helping the surgeons navigate and maneuver in the interior of the abdominal cavity, Automated Medical Products Corp. has configured some of their existing offerings to assist laparoscopic surgeons with certain complications that occur outside of the body.

Automated Medical Products fundamental instrument for thirty years has been the Iron Intern[TM], a device that functions similarly to a human arm and can lock into place to hold retractors during open surgery. In response to the growing popularity of laparoscopy, a surgeon familiar with the Iron Intern developed a series of clamps to address the needs of laparoscopic surgeons. Dr. Jerry Brown, President and CEO of Automated Medical Products describes the process. "The Iron Intern was used for open surgery, then Dr. [Robert J.] Greenstein [M.D.] started doing laparoscopic surgery and experimental surgery and needed it to hold laparoscopic instruments. So, he designed the LC1, LC2, and LC3 Greenstein Gripper Clamps. Each clamp does different firings, but they all fit into the Iron Intern and hold laparoscopic instruments. Laparoscopic instruments were, for the most part, hand-held instruments, but if you are holding a trocar that you are going to insert something through, it gets tiresome after a while. With the Gripper Clamps, the Iron Intern holds it for you, and you don't have to struggle with a camera end that's moving."

Another effective laparoscopic tool that can be used with the Iron Intern is the Nathanson Hook Liver Retractor. These books are specifically designed to retract and hold the fiver out of the way for the duration of a laparoscopic surgery. Available as a set of three (small, medium, and large) the Nathanson Hooks fit into the Iron Intern and can be positioned for optimum surgeon visibility and access.

The Iron Intern is constructed in single arm and double arm configurations to hold a combination of retractors and instruments as the need should arise. It is designed to fit on any existing table rail to accommodate use anywhere in the world.

In addition to the Iron Intern and its set of accessories for laparoscopic procedures, Automated Medical Products also offers a selection of instruments for laparoscopy, including the O'Brien Lap Band Set[R] for the Lap Band gastric banding procedure, an extra long articulating dissector, and an eccentric "Y" adjustable finger retractor for fundoportal dissection with challenging gall-bladders. Another new offering is the Deep Suture, a device that is designed for the safe and easy closure of the fascia during minimally invasive surgery. In two simple movements, the Deep Suture places the needles and sutures and drives then1 through the fascia, all the time under video observation. Easy to clean and easy to use, this device makes closing trocar holes fast and simple.

Just a few years ago, laparoscopy changed the way surgery was performed for a number of procedures. Now, with laparoscopy continuing to grow in popularity and increase in applications, new and emerging technologies are once again opening a whole new world of surgical possibilities.

For Information On The Companies In This Article

Automated Medical Products Corp.

Use InfoLINK 4H1701 or Call 800-843-1191

Cardinal Health

Use InfoLINK 4H1702 or Call 800-843-1191

Olympus Surgical

Use InfoLINK 4H1703 or Call 800-843-1191

US Surgical (Auto Suture Division)

Use InfoLINK 4H1704 or Call 800-843-1191
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Title Annotation:Technology solutions: laparoscopy
Author:Ritsma, Rich
Publication:Surgical Products
Geographic Code:1USA
Date:Aug 1, 2004
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