Laparoscopic graspers are designed to hold the tissue firmly without exerting excessive pressure. The shaft on most of these instruments is 5 mm in diameter, 31 cm long, and isolated by a thin layer of plastic (Teflon or polyvinylchloride) that electrically insulates the instrument. The grasping blades are blunt and are about 2 cm long with a maximum jaw span of about 2 cm. Although the quantity of tissue that can be held with these graspers is limited, we use this type of grasper for almost all purposes during laparoscopic colorectal surgery (Figure 2.11). The surface area of the blades is large enough to safely hold a sufficient amount of tissue, whether it is mesentery, greater omentum, or intestine. To maintain a relatively safe grip, the inner side of the blade is serrated; the serrations are fairly atraumatic, so that the intestine can gently be grasped with this instrument. The grasper usually has a holding mechanism that is easily activated and released with a trigger.
Special dissecting instruments are useful for laparoscopic colorectal surgery. Their tips are usually more pointed than that of laparoscopic graspers, but still blunt. The blades are about 2 cm long, and are curved similar to a small curved hemostat and thus facilitate blunt dissection. Similar to the laparoscopic grasper, the shaft is 5 mm in diameter, 31 cm long, and electrically insulated. The dissector can act as a forceps during delicate dissection and can also be used for electrosurgery. Both the grasper and dissector have a dial on the handle that allows the tip to be easily rotated on its longitudinal axis. For additional maneuverability, an articulated tip is also available; a second dial moves it.
The third type of grasping instrument is an Allis-like clamp. The opposing surfaces of the blades are smaller than those of the normal grasper so that the tissue can be held more precisely. The smaller surface area and shape of the blades is very useful in certain special situations, especially in grasping bleeding vessels or the center-rod of a circular stapling instrument.
Scissors are among the most important instruments in advanced lapa-roscopic surgery. Because they are used for both sharp and blunt dissection, they should have very sharp blades and a blunt tip. We do not use microscissors with small blades or the hooked scissors frequently used in gallbladder or gynecologic laparoscopic surgery because the wide dissection of mesentery and lateral and dorsal attachments of the colon can be more quickly performed with normal curved laparoscopic scissors.
The scissor shaft is 5 mm in diameter, 31 cm long, and is well insulated so that electrical current can safely be applied. The curved blades are 16 mm long with a maximum jaw span of 8 mm. The shaft can easily be rotated in its longitudinal axis by using a dial on the handle. We use the scissors for sharp and blunt dissection and for tissue desiccation, which should always be performed with closed blades. Sometimes, arcing will occur during tissue desiccation, and the extremely hot arcs may result in dulling the scissors. If the surgeon wants to desiccate the tissue while cutting, bipolar scissors should be used that combine bipolar desiccation with mechanical cutting. Because the cutting blade is ceramic in these scissors, it will neither melt nor become dull.
Optimal exposure of the operative site is the key to success in any lapa-roscopic surgery. In colorectal surgery, most of this attention is directed to the small intestines, because they normally spill into all quadrants of the abdomen. Retracting instruments are mandatory if the procedure is to be successfully performed in obese patients or those with a distended intestine. The truly effective, safe, and reliable laparoscopic bowel retractors are, however, not in our hands yet.
Laparoscopic retractors often used in general laparoscopic surgery are not effective or even dangerous for colorectal practice: For instance, we do not recommend using a one-finger or a fan retractor to retract bowel loops. These designs may be useful to retract the liver or other more fixed organs, but they are not designed to retract the bowel effectively. Fan retractors also have the disadvantage that an intestinal loop may become trapped between the fingers of the retractor, exposing the loop to potential injury.
Eventually, displacement of the small bowel loops is performed most effectively using grasping devices and by gravity. Before starting the procedure, the small intestinal loops are positioned to one side of the abdomen by changing the patient's position and with gentle laparo-scopic manipulation. If the small intestines still migrate into the operative field after the above technique, use of atraumatic a pad-type retractor (Endo Paddle™ Retract, USSC, Norwalk, CT; Figure 2.12) can be considered.16
Even after intracorporeal mobilization/transaction, the freed segment of the colon itself can also obstruct the remainder of the procedure. Safe and effective retraction of the transected colon can be achieved by an endoscopic snare device (Endo Catch™ II, USSC) with its plastic bag
removed. The snare, which is passed into the abdominal cavity inside a 10-mm-diameter tube, can be opened to a maximum diameter of about 6.5 cm and then completely or partially closed by retraction into the tube. Because the snare consists of a band of spring metal with blunt edges, it is not likely to injure the bowel if used properly. After the colon has been divided, the sling is slid over the end of the colon, and is used to retract it. Thus, not only does this sling work as a safe retractor, but it can also allow rotation of the intestine in the longitudinal axis of the instrument and facilitate dorsolateral dissection of the colon on the right or left side. The snare theoretically can be applied without transecting the intestine. One side of the loop can be detached, passed around the intestine, and then reattached. The sling may also be used to occlude the rectum before rectal washout, which is usually performed before rectal transection during rectal cancer surgery.
Despite several useful retracting techniques mentioned above, if the intestine is distended, if the patient is overly obese, or if space in the peritoneal cavity is limited in some other way, it can be difficult or sometimes impossible to expose the operative field sufficiently in laparoscopic colorectal surgery. If necessary exposure cannot be achieved, prompt conversion to HALS or open surgery should be considered.
A specimen bag is very useful for laparoscopic resections for colorectal malignancy to isolate the resected specimen from the peritoneal cavity. This may reduce the possibility of seeding tumor cells into the peritoneal cavity and abdominal wall. In general, a bag has to be inserted into the peritoneal cavity in a compressed manner and then opened. The bulky specimen may then be placed in the bag, and the bag completely closed before bringing it through the abdominal wall.
The ideal endoscopic bag for delivering the intraabdominal specimens should have the following properties:
• It should be fluid-impermeable and be strong enough so that it cannot be damaged inside the abdominal cavity or when being removed.
• It should fit through a cannula 15 mm or smaller.
• It should be large enough so the entire intestinal specimen, including mesentery, can easily be placed in it in one piece.
• It should have a mechanism to quickly close the bag to prevent spills.
Our current choice is the specially designed commercially available bag, which allows excellent control of the mouth of the bag and a good drawstring mechanism (Endo CatchTM II, USSC; Figure 2.13). Using a plunger-type mechanism, the bag is expelled from the shaft once the tip of the instrument is inside the peritoneal cavity. It is initially attached to a metal hoop that holds the mouth of the bag open. Once the specimen is placed inside the bag, the drawstring is tightened, the bag is torn away from the metal hoop, and the hoop and neck of the bag are drawn up inside the metal shaft of the instrument. The cannula incision is then enlarged and the neck of the bag, including the purse string, is delivered to the anterior abdominal wall.
Clip appliers were developed to facilitate ligation of small ductal structures approximately 3 to 8 mm in diameter. The most common dispos-
able clip appliers contain up to 20 clips and are available in 5- and 10-mm-diameter instruments. They are manufactured from a variety of materials, including absorbable polyglycolic acid and polydioxane, stainless steel, and most often, titanium. Clips are practical and effective if an electric vessel sealing device is not available, because clips require less time to apply than sutures and knots in laparoscopic surgery. In truth, the role of clips in our practice is greatly diminished, and we rarely use them. Nonetheless, they should be kept available.
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