Small Animal Laparoscopy and Thoracoscopy. Группа авторов
punch.
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Scissors
In veterinary surgery, endoscopic scissors are used for more advanced procedures, such as for transection of the common bile duct in laparoscopic cholecystectomy, transection of the pulmonary ligament of a caudal lung lobe in thoracoscopic lung lobectomy, thoracoscopic subtotal pericardiectomy, or cutting intracorporeal sutures (Figure 4.7). Curved Metzenbaum scissors are the most versatile for tissue transection and dissection. When used with a handle–shaft assembly with a connector for monopolar electrocoagulation, hemostasis may be achieved while cutting. Metzenbaum scissors are also available with straight blades and with long, fine blades (curved or straight) for finer dissection. Other dissecting scissor types include operating scissors with serrated blades, blunt‐tipped scissors, sharp‐tipped scissors, and micro‐dissection scissors. Blades can be fine or robust, long or short, and straight or curved for most scissor sizes and shapes. Hook scissors have a wider, single‐action blade that engages a thinner, stationary blade. Both blades are hooked toward each other. Hook scissors are used to cut suture intracorporeally, and the hook design hinders suture slippage during transection of the suture. All scissors are used with nonlocking handles.
Tissue Retractors
Palpation probes are very useful instruments and should be included in every laparoscopy pack (Figure 4.8a). Palpation probes are single‐piece instruments with straight handles that come in 3‐ and 5 mm diameter sizes to fit through 3‐ and 5‐mm cannulas. They can also be used with a 10‐mm cannula if a reducer cap is used. They have long, thin shafts that are marked in centimeter intervals to help with measurement of lesions within the body cavity. Whereas 3‐mm palpation probes are available in 20‐ and 30 cm lengths, 5‐mm probes are available in a 36 cm length. Probes can serve many different functions, starting with the obvious palpation of organs and structures within a body cavity. They can also be used in a sweeping motion to move and retract organs such as the intestines, omentum, or spleen out of the viewing field, such as during laparoscopic ovariectomy or gastropexy, and they can be used to help stabilize organs during tissue dissection or ligation.
Figure 4.7 Endoscopic scissors (from top to bottom): straight scissors; curved Metzenbaum scissors; serrated Manhes scissors; scissors with curved, conical, serrated blades; scissors with spoon‐shaped blades; Manhes micro scissors; straight microdissecting scissors; curved microdissecting scissors; and hook scissors.
Source: © 2014 Photo courtesy of KARL STORZ GmbH & Co. KG.
Several different kinds of retractors are available for human MIS. Of these, only the fan retractor is regularly used in veterinary surgery (Figure 4.8b). The fan retractor consists of a straight shaft with a series of flat blades at the end that distend in the shape of a paper fan when the outer sheath of the shaft is rotated. The completely opened retractor is sturdy and is used to retract organs with large surface areas, such as the liver or intestines. It is often used for advanced procedures such as laparoscopic cholecystectomy or adrenalectomy. Fan retractors are available in both 5‐ and 10 mm diameter sizes.
Figure 4.8 (A). Palpation probe with centimeter markings. Inset shows detail of the instrument tip. (B). Fan retractor. Inset shows detail of the collapsible fan blades at the working end.
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Figure 4.9 Retractors used in human minimally invasive surgery (from top to bottom): Cuschieri retractor with end deployed (A); retractor for gastric banding, with close‐up of working end (inset) (B); Leroy H‐retractor, with close‐up of working end (inset) (C); and Leroy T‐retractor with end deployed, with inset showing the closed end (D).
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Other types of retractors that are widely used in human laparoscopic surgery include the Cuschieri retractor, gastric banding retractors, and Leroy retractors (Figure 4.9). The Cuschieri retractor was designed as safe retractor of the liver for extended periods of time during laparoscopic surgeries. When activated, the distal end roughly resembles a hexagon, allowing for support of a larger surface area. When closed, the retractor can also be used to move and retract other abdominal structures, such as the intestinal tract. A similar principle is used and advanced upon in newer designs based on the Cushieri articulating retractor. A variety of retractor shapes are available, including curved, triangular, circular, and pretzel shapes. Gastric banding retractors have a flat, angled distal end that is used to bluntly retract the stomach and intestines. A fenestration at the end of the instrument is used to secure a gastric band for passage around the esophagus. Leroy retractors come in a variety of configurations and are used in human colorectal surgery. These retractors may become more widely used as surgeons begin to perform more advanced procedures.
Ovariectomy hooks are used during laparoscopic ovariectomy and ovariohysterectomy to suspend the ovary against the body wall to facilitate ligation and transection of the ovarian pedicle (Figure 4.10). Ovariectomy hooks are placed percutaneously to capture the ovary and proper ligament within the curve of the hook. They have a heavy, T‐shaped handle to facilitate retraction and to prevent rotation of the hook after being placed. The heavy handle allows positioning of the instrument without an assistant, and the small puncture that is created does not need to be closed. Both small and large ovariectomy hooks are available to accommodate patient size. A straight‐handled hook may be used in some clinics but is no longer manufactured. When ovariectomy hooks are not available, a large diameter suture on a large needle (i.e., 0 polypropylene on a CT‐26 or CT‐40 swaged needle) can be used to capture and retract the ovary in the same manner.
Figure 4.10 An ovariectomy hook with a T‐shaped handle.
Source: © 2014 Photo courtesy of KARL STORZ SE & CO, KG.
Needle Holders and Suturing Devices
Different methods of suturing for advanced laparoscopic