One2 14b Fundamentals of Laparoscopic and Robotic urologic surgery

• Neonatal………..20 cm 
• Pediatric……..28 cm 
• Adult………….36 cm  
• Morbid Obese………..45 cm

• Halogen (150W) - has yellow light, electrodes made of tungsten filament, life 200 hours, since it has less half life - two bulb are given
• Halogen halide (250W)
• Xenon (300W) - has slightly bluish tint, light more natural compared to halogen, life 500 hours
• LED - 30,000 hours, 90% reduction in power

• Two properties of light source
• - Intensity (150W to 400W, optimal is 250W)
• - Color temperature -

• Light travel by total internal reflection
• Each fibre - 20-150 micron
• The broken fibers are seen black spots
• light is only seen in the tip, if seen in the middle, it is the broken fiber
• Light cable should not be bent acutely. To avoid breakage, the radius of light cable should be less than 15 cm in radius

• Has two parts
• - Coupler - it is coupling telescope with lens of camera. It has two lens. It is pupil of camera
• - CCD (Charged Coupler device) Inside is a green colored chip. THis is retina of camera. It can be single chip or 3 chip camera.

• 3 chip has better color contrast compared to single chip
• In single chip - everything appears reddish, if bleeding starts, you are in trouble
• In 3 chip - red color cannot show dominancy, other colors are also seen so, image is clear

• Camera add counter color to remove impurities
• Always keep entire screen white and press white balance

• Focus at focal length. Focal length of
• - 10mm telescope - 10cm
• - 5mm telescope - 5cm
• - 4mm telescope - 3-4 cm

• If glare - increase shutter speed
• If dark - decrease shutter speed
• Aparture
• - large in laparoscopy, laparoscopic lens are large, so larger aparture should be opened
• - small in hysteroscopy
• Fibroscope filter - filters disturbance in underwater imaging
• - ON - in hysteroscopy
• - OFF - in laparoscopy

• 30 degree scope - 152 degree
• 0 degree - 76 degree

• Cathode ray tube (CRT) monitor
• SD - resolution 650
• HD -
• ULtra HD (4K)- 3840 pixel by 2160 pixel

The retractors are either disposable or nondisposable. The nondisposable instruments can be dismantled, so that they can be cleaned and reused. The parts of the instruments are:

1. Handle - This can be plastic or metal. The parts of the handle are finger grip, Rotating knob, Release button to release the inner and outer sheath and Cautery attachment. The handle of the ‘hand held’ laparoscopic instruments have either a locking or nonlocking mechanism. The locking mechanism includes a ‘ratchet’ mechanism for locking (Storz) or a button mechanism (Wolf). The locking mechanism helps the surgeon to maintain the instrument in a fixed position and hence avoids fatigue in prolonged surgeries.

2. Insulated outer tube - The outer tube may be insulated or noninsulated. The insulation coat is likely to be breached during cleaning and may be dangerous as this may lead to inadvertent injury during the course of surgery. The surgeon should make sure that the insulation cover is not breached prior to commencing the surgery.

• 3. Inner tube which is part of the tip of the instrument - The insert of the instrument can be a scissor, grasper or forceps, Maryland, Allis, etc. The insert is locked by rotating the distal end and clicking on the lock. Most graspers and dissectors are used in their 5-mm size but are available in a range from 3 to 12 mm in predominantly reusable forms. Grasping instruments have either single-action (only one jaw moves during opening) or double-action (both jaws move) tip design. Tip designs include blunt-coarse, pointed (dolphin), straight (duckbill), curved (Maryland), and angled. The surface of the jaws may be atraumatic or traumatic.
• Serrated or smooth surfaces allow gentle tissue manipulation in atraumatic graspers (e.g., bowel forceps with a 3-cm long grasping jaw). Traumatic graspers have toothed or clawed surfaces on their jaws to allow them to grasp and holdtissues firmly.

Available either as a disposable or reusable needle.

• Available in three lengths 8, 10 and 12 cm
• 14 gauge in diameter. The reusable needle is larger in diameter (3 mm)

The tip has two components. The inner component is blunt and projects just beyond the tip of the sharp needle (for 3 mm). The sharp needle (outer beveled sheath) helps in penetration of the needle across the fascia into the peritoneal cavity, once the needle enters the negative milieu of the peritoneum, the sharp tip retracts, this helps in preventing injury to the intraperitoneal organs.

Flow rate shoule be placed on 6-10 per minute. For example, if you keep the flow rate to 45/minute, if there is leak during surgery, if more than 10 liter/minutes for more than 10 minutes, then, there will be dryness of the intestine and chance of hypothermia. Insufflator will automatically increase the flow if there is a leak and compensate the leak. If we set the flow rate to less than 10, the flow rate cannot compensate the leak rate, and the abdomen will collapse. This collapse will compel the surgeon to look for any leak

Veress needle only allow the flow rate of 2.5 l/minutes. But, more than 1l/minutes is risky. If you accidentally prick vein in flow rate of 2.5l/min, there is high chance of air embolism. Once you enter the abdomen and initial 500ml to 1l air has gone, and you are sure that, needle is in peritoneal cavity,  you can now raise the flow rate to 2.5l/min.


Before placement of trocar, raise pressure to 12


Maximum about of gas that is allowed to create pneumoperitoneum before placing the trocar is 6L. The amount depends on size of patient, muscle relaxants, bowel preparation, and parity. 

Within 100-200ml of insufflation, liver dullness disappear.  


High capacity insufflator can be useful during bleeding, when you need to increase the abdominal pressure to compensate the pressure reduction by the suction.


In an ideal condition, if there is no leak, the minimum amount of gas consumed in one hour is 18L. 20% of CO2 is absorbed by peritoneum and there is some leak while changing the hand instruments, changing the trocar.. 

The average amount of gas consumed by good surgeon in one hour is 90-100 liter.. 

If the gas consumed is greater than  300-400L, then check the instruments if there is any leak, change disposable trocar and cannula. 





Long press to the set flow for 3 seconds - changes the flow rate fast

Volume of cylinder - 22 L CO2 /Kg 

2 KG cylinder - 44 L, can easily perform one surgery


Cylinder shoud always be placed erect, and never be kept upside down. If placed upside down, liquid CO2 will spoil your insufflator. In central supply also, there should be filter to absorb moisture. Moisture is big enemy of insufflator.

• Quadromanometric Indicators - includes 
• •    Preset Insufflation pressure,
• •    Actual Pressure
• •    Gas flow rate and
• •    Volume of gas consumed

• preset pressure - 12
• Actual pressure - 6 mmHg
• flow rate - 1
• Total Gas - 12 l
• Condition - IVC insufflation, 6 is pressure of IVC, 1 is flow rate of veress needle, in preperitoneum 12L cannot accomodate

• preset pressure - 12
• Actual pressure - 5
• Flow rate - 0.5
• Gas Used - 500ml
• Condition - preperitoneal insufflation, maximum capacity of preperitoneal space at 12mmHg is 1 L

• preset pressure - 12
• Actual pressure - 12
• Flow rate - 0
• Gas used - 100ml
• Condition - in rectus, muscle or fat. Only 100ml fat has gone.. These structures are not stretchable membrane and cannot make cavity within the muscle

• preset pressure - 12
• Actual pressure - 40
• FLow rate - 0
• Gas used - 200 ml
• Condition - obstructed systemm

• preset pressure - 12
• Actual pressure - 12
• FLow rate - 1
• Gas used - 1 L and there is unilateral distension
• Condition - you are inside bowel. In bowel, you cannot put more than 1l/min.

• Three parts
• - cone shaped sleeve
• - Metal/Plastic sheath with trumpet/flap valve
• - Blind tipped trocar

The Hassan’s cannula offers the advantage of reduced risk of injury to the bowels. It is especially useful in a patient who has previously undergone intra-abdominal procedures

• Original Hasson Technique - suture is used
• Modified Hasson Technique - Kocher Forcep used

In hassons technique, incision should never be given in base of umbilicus, because at that site, all the structures are fused. Pull the crease of umbilicus with allis and make longitudinal incision over lower crease of umbilicus. Apply allis on either side. Separate the fat and catch the rectus with Kocher. Use two Kocher to lift the anterior abdominal wall. If the skin was cut longitudinal, cut rectus transversely. Cut only rectus and not other structures. Blunt puncture with hemostat. Insert 'S' retractor and take full bite on rectus. Take bite on each side. Insert Hasson cannula and adjust it according to the thickness of anterior abdominal wall. Stabilize suture to adjust the cannula. You dont need to tie the suture. you just need to insert the suture in groove and fix it there.

Bowel injury is similar in hasson technique and veress needle technique. However, vessel injury is far much less in hasson technique as compared to veress needle technique.


Flow rate in open technique should also be 1l/min. Abrupt flow may lead to vasovagal shock.

• 5mm - operating port
• 10mm - optical port
• 12mm - robotic optical port, used for staplers
• 15mm - for morcellators

• - Trocar/obturator - it has eye that gives hissing sound, back is head
• - Cannula - shaft (has air inlet) and valve (flap valve). Flap valve has rubber seal that has to be changed after each 5-10 surgeries

• The trocars can be classified in the following ways:
• - Disposable (plastic)
• - Nondisposable (metal)

• They can also be classified as:
• - Bladed trocars
• - Nonbladed trocars

How to know if the valve or outer washer is defective? - When you  keep the instrument, if the gas is leaking, the outer washer is defective because the valve is open while keeping instrument. If the gas is leaking without keeping the instrument, the valve is defective

• - Blunt
• - Pyramidal - mostly used
• - Conical
• - Safety trocar

• - Blade inside - you need to charge it by pressing a button
• - YOu should always go in one go, you cannot rotate, if you rotate or hesitate to go in one shot, it will discharge
• - The blade is very sharp
• - Once it is discharged, the blunt tip comes, and you cannot go
• - If you use it multiple times, the blade will not go back due to blood or pus, and may cut structures

• - 20cm - for fat people
• - 12cm - for adult people
• - 8 cm - for pediatric

• Head of trocar in thenar eminence - that keeps hole blocked
• Middle finger wrap around air inlet - middle finger should press port towards thenar eminence
• Index finger along the sharp end - that prevents overshooting
• Rotation movement should be at the level of elbow
• Sharper trocar are safer than blunt trocar. In blunt trocar, more force is required to enter, that may lead to overshooting and high chance of injury. For eg, bullet is blunt, but, because of velocity, it has more injury effect.
• YOu should not go in Z fashion, - more chance of injury

• The Visiport (a kind of optical trocars) is a disposable and expendable visual entry tool which includes a cannula and hollow trocar.
• Introduce with 0 degree telescope. On each firing, 0.5mm blade comes out and cuts tissue layer by layer under vision and slowly enters the peritoneum.

Tip of trocar has oblique knife. Keep on screwing the abdominal wall and it enters the abdominal wall.

• 1.5mm - ureteroscopy
• 1.8mm - office hysteroscopy
• 4mm - cystoscopy, hysterscopy
• 5mm - Laparoscope
• 8mm - single puncture sterilization
• 10mm - standard laparoscope
• 12mm - in robotic surgery, for 3D imaging

Larger diameter - brigher image

• Eye piece
• light adaptor
• Shaft
• Objective lens

Quality of telescope

• More rod lens is there, less air gap is there leading to better telescope.
• In telescope, it is written
• - E-class
• - HD telescope - more number of rod lens. It is 3 times expensive than E-class

Most of the light fibers are in top. Even in zero degree, the telescope should be straight. Light comes from above, and we are habituated to see the shadow below.

• The most commonly used laparoscopes have 0- or 30-degree lenses (range, 0 to 45 degrees) and are available in sizes from 2.7 to 10 mm.
• Typically, the 30- degree lens provides the surgeon with a more complete view of the surgical field than the 0-degree lens, allowing the surgeon to peer around vascular structures by rotating the lens. 
• With standard laparoscopes, image transmission uses an objective lens, a rodlens system with or without an eyepiece, and a fiberoptic cable.
• From the eyepiece, the optical image is magnified and transferred to the camera and onto the monitor. Light is transmitted from the light source through the  fiberoptic cable onto the light post of the laparoscope
• To prevent fogging, laparoscope should be warmed before passing into the abdomen, wipinng the tip with povidone iodine solution is also recommended 
• 3D laparoscopic system uses two-lens system

• - long reducer -
• - Short reducer - top mounted reducer
• Long reducers are better. Needle are trapped by the valve of short reducers (top mounted reducer) and you need to blindly insert the needle or blindly remove the needle that increases the chance of injury. In long reducer, you can insert the needle holder through the reducer, pull it to hide inside the reducer and then insert under vision. The reducer is 8mm in diameter and only head is 5 mm, and it bypasses the valve.
• Reducer are not required in disposable ports. In disposable, there inbuilt reducers that have radially dilating reducers. You can directly insert needle or remove the needle directly, no need of additional reducers.
• Disposable cannula has valve that allow only air movement in one direction. That is the reason, the needle will not come back from this valve.
• Disposable ports are expensive. If you are using disposable, you are rich. If you are using disposable as reusable, you are very poor.
• Reusable are safer ports.

• If you are a surgeon
• Thumb - In a back hole
• Ring finger - in front hole
• Middle finger - for supporting instrument
• Index finger - rotating knub
• Little finger - For ratchet

• If you are assiting
• - with thenar eminence and fingers

• Handle
• Sheath
• Inside instrument
• If any part of laparoscopic instrument is broken, you can order each unit separately - handle, sheath or inside instrument

Dissamble every time after completion of surgery and clean all parts.

• Double action - bowel holders, less traumatic
• Single action - needle holders, more traumatic

Its rule in laparoscopy that, in single action instrument, the moving jaw should be up.

• Atraumatic grasper - fenestration, no serration, double action (both jaws are moving). It is the first instrument to insert before doing any type of surgery.
• Semitraumatic grasper - serrations are very deep, when you hold anything with this grasper it will not slip, use this grasper to hold any structure that you are planning to remove
• Traumatic grasper - a replica of allis forceps, Traumatic graspers have toothed or clawed surfaces on their jaws to allow them to grasp and hold tissues firmly, never used in bowel - causes perforation

• Tip designs include blunt-coarse, pointed (dolphin), straight (duckbill), curved (Maryland), and angled
• Maryland - Curved, replica of artery forceps, it is traumatic so never use it as a grasper, it has function of stripping, hemostasis and creation of window
• Bipolar Maryland - called as Robi Dissector Forceps, even if you don't have ligasure or harmonic, it can give a good function
• Bipolar forceps - more durable than Robi dissector, in simple surgery where bipolar is required, use bipolar forceps, in complex surgery, use Robi dissector
• Right-angled Maryland - useful during nephrectomy

• Hook scissors - in laparoscopic surgery, there is problem of engagement. In simple scissors, it is difficult to engage in laparoscopic surgery. Hook scissoors cut without letting slippage, cuts distal to proximal, it never overshoots
• Straight scissors
• Curved scissors - both limbs are visible
• Microscissors

• Straight needle holder
• Curved needle holder - different for left and right hands
• Self aligning needle holder - you dont need to do anything to align the needle. Disadvantages - it does not hold the tip to take it out, it cuts the suture, so it is not useful for tying knot (it is useless)

• Endo ski needle - distal 1/3rd is curved, proximal 2/3 is straight, you take a bite and simply take out the needle straight without need of rotation
• Curved needle - taking bite is easy but need to rotate while removing the needle

• Titanium and nitinol are two metals that are used in laparoscopic surgery because they are inert.
• Nitinol - used in staplers, used by CTVS surgeons when they do bypass of artery
• Hemolock is made up of silicon. 
• Hemolock has no issue with MRI. Titanium may have issue with MRI.

• Keep the clip on flat surface, hold in the shaft of clip applicator, and press the clips on which the clips will be automatically get loaded, never hold the handle
• Press the clip applicator for 3 seconds while applying the clips
• Apply second clip 3 mm beyond, if you apply too near - both clips will be loose because dumbell of first will be nullified by dumbell of second
• The jaw of clip applicator can be removed and any size can be placed and screwed it tightly. If you dont screw it tightly, the clips will not be applied tightly. There should be dumbell formmation in vessel to confirm that the clip is tightly applied.

• • Complete circumferential dissection of the vessel
• • Visualization of the curved tip of the clip around and beyond the vessel, often with the curved end of the clip placed between the artery and vein
• • Confirmation of the tactile snap when the clip engages
• • No cross-clipping 
• • Not squeezing the clip handles too hard (compared with the application of metal clips)
• • Careful removal of the applier after application is given; the tips are sharp and can cause a laceration of nearby vessels  (e.g., renal vein)
• • During transaction of vessels, only a partial division is performed initially to confirm hemostasis before complete transaction
• • Minimum of two clips are placed on the patient side of the renal hilar vessel
• • Application of at least two clips on the stump of the artery and that a 2-mm cuff of artery should be left distal to the clips

Electrocoagulation must be avoided in the vicinity of clips placed for occlusion of vessels to prevent conductive tissue necrosis and subsequent clip dislocation. To ensure reliable function, the closed ends of the occlusive clips must be seen extending slightly beyond the targeted vessel and should be  placed perpendicular to the longitudinal axis of the vessel.

• -  green (medium), (violet) large medium and (gold) extra large
• -  The color code is for the clip applicator and color code knob is located on the clip applicator

• 
• Hemo-o-lock clips are polymer clips, 6 clips in each cartrige 

Up to 10 mm of tissue can be ligated through a 5-mm trocar, and up to 16 mm of tissue can be ligated through a 10-mm  trocar.

• Noninterlocking titanium clips
• - 200 (white)
• - 300 (green) and
• - 400 (yellow)

[@ WHY - WGY - White, Green, Yellow - 200, 300, 400]

Each staple load cartridge is color-coded depending on the size of the staples: 2.0- mm staples (gray) or 2.5-mm staples (white) are preferred for vascular (renal vein or renal artery) stapling, whereas 3.8-mm (blue) and 4.8-mm (green) staples are used in thicker tissues (ureter, bowel, bladder).

• Aspiration needle - to aspirate distended gall bladder, to aspirate ovarian cyst
• Myoma screw - used during hysterectomy
• Retractors -
• Suction - In laparoscopy, its universal that, away from you is irrigation and towards you is suction
• Retractors
• - Fan retractors
• - Nathanson Liver Retractor Systems
• Uterine manipulators
• - Roomy uterine manipulator
• - Colpotomizer uterine manipulator
• - CF uterine manipulator
• - Marva Uterine Manipulator
• Stryker Mini alligators - microinstrument (1.8mm), can be introduced into the abdominal without the port, can be used to hold any structure
• Endoknife - can be used as replacement of morcellators