Hand held instruments
Contrary to what instrument manufacturers may tell you, you do not need lots of new instruments. What you do need are atraumatic, robust instruments that are easy to put together and clean. Most of the instruments on our general laparoscopic sets are redundant when it comes to colorectal work.
What would BLA consider ESSENTIAL?
Two pairs of needle holders
Having used Nykomed, Olympus and Wolf instrumentation over the last ten years, our personal preference is to use the Karl Storz Macro needle holders. Either straight (product Nos. 26173 MC & 26173 ML) or curved handles (Product Nos. 26173 KC & 26173 KL). Both retail at £ 726.00 each – a remarkable price! The curved handles are particularly ergonomic when suturing deep in the pelvis or in an obese patient. They are very precise at both needle and suture capture. A wonderful piece of engineering.
Alternative models include Ethicon Endosurgery's straight handled needle holders (retail at £ 1,000 each) which we have used in over 100 laparoscopic pelvic floor repairs without regret and Richard Wolf (see below). Whilst the latter model does have ergonomic handles and strong tips, the release catch can be rether difficult to release. Again, like all Wolf instrumentation, the nursing staff need to learn how to pit them together. The Ethicon needle holders would be our second preference to Storz.
Stryker also offers a fully reusable range of laparoscopic instrumentation range to satisfy the needs of Bariatric, Urology and General surgeons.
Our advice is to try them all and see which one you are comfortable with.
Self correcting/writing needle holders are unnecessary and are no excuse for not learning/practicing intracorporeal suturing. In addition, they can’t really be used for anything else (holding tissue, sutures etc).
Ethicon-Endosurgery market Suture Assistant, a sterile, single-use instrument designed to help place a laparoscopic intracorporeal suture with a secure knot. The knot is secured by just pushing a button. Whilst the technology is very impressive, cost issues clearly comes into the equation. Whilst it could be justified in the private sector for fundoplication, intracorporeal suturing is an essential skill and once mastered can be very quick. Have a play with it when you go to Hamburg! Auto suture produce a similar product Endo Stitch.
If you undertake a lot of surgery, learn ventral rectopexy, CBD exploration and fundoplication you will almost certainly need two if not three pairs. Again, don’t penny pinch.
- Two pairs of atraumatic graspers (for each instrument set).
For colorectal work our preference has been to use 36cm 360 degree rotating Johan forceps Karl Storz (Product No. 33222C which retails at £ 481.00) with plastic Mantis type ratchets.
They are very easy to assemble and have proven durability. We consider it important, if not essential to use the model with two moving fenestrated jaws as their grip on tissue (bowel) is weaker than what you would get with a Johan fixed jaw grasper. As a result, bowel always seems to fall out of the forceps and if the surgeon applies too much force, the graspers break. The latter is much more preferable to tearing the bowel.
It is for this same reason why we do not recommend you ever use Babcock retractors. If you do use the latter, never let an inexperienced assistant hold them.
It is also worth having two separately packed 43cm Johan graspers Karl Storz (Product No. 33422C) when extra length is required eg a high splenic flexure. You will certainly need them for bariatric work.
Karl Storz Endoscopy UK
392 Edinburgh Avenue
Stryker also offers a fully reusable range of laparoscopic instrumentation range to satisfy the needs of Bariatric and General surgeons.
Stryker UK Limited
RG14 5EG UK
Phone :+44 (0) 1635 262400
Fax :+44 (0) 1635 580300
In our Urology and Upper GI work where grip strength is perhaps much more important, we use either fenestrated MicroFrance or Storz Johans with one fixed and a single moving jaw (see below). We have used them in over 400 urological cases and 1000 fundoplications without any problems. They can also be used as an auxillary needle holder.
Again we have gone for 360 degree rotating Johans and the same ratcheted Mantis handle as Storz (ease of application and release).
MicroFrance laparoscopic instruments are available from their UK distributor:
Surgical Instrument Group Holdings Ltd,
89A Gloucester Road,
Tel: 0845 310 1103
Fax: 0208 683 1105
An alternative is Applied Medicals A-Trac laparoscopic grasper. These are very popular with the Brisbane colorectal surgeons.
However, they only come in 10mm. Whilst it may just be us, BLA feal that another limiting feature is the design of their on-off ratcheting handle. We also think that the disposable option is an unnecessary costly luxury that in todays financial climate would not help progress any laparoscopic colorectal business case
Another luxury, but none the less one worth having is the Richard Wolf anvil grasping forceps (Product No. 8397.652 at £671.00); can be useful in connecting the anvil to the staple gun. A cheap alternative is ordinary crocodile mouthed graspers.
However, in our opinion we would generally not go for Wolf instrumentation for a number of reasons - theatre nurses find the interchangeable instrumentation difficult to put together. Whilst we would hope that training would overcome this hurdle - it hasn't. In addition we do not like the ratchet system (can be/is very difficult to release). This is however only personal prefference.
Richard Wolf UK Ltd Waterside Way Wimbledon
London SW17 0HB United Kingdom
Tel: 020 8944 7447 Fax: 020 8944 1311
Vascular & intestinal clamps/applicator
If you plan to undertake any advanced laparoscopic interventions (eg., partial nephrectomy) it is essential that you have a clamp applicator and at least two vascular clamps available. Clearly you should also be familiar with their use. The same applicator can also be used to apply intestinal clamps eg in performing intracorporal bypass prcedures.
BLA have used Micra Frances 10mm Prince Prose Clamp Applicator CEV560 for a number of years (see below).
Clamps come in pairs; vascular clamps (CEV 565) and intestinal clamps (CEV 567). They also market a CBD clamp which we have not used. An other alternative, of which we have no experience is a laparoscopic Satinski clamp.
CEV-560 MICROFRANCE Begin Clip Applicator £799.00
CEV-565 MICROFRANCE Begin Vascular Clip (30mm): 2 pieces £190.00
CEV-566 MICROFRANCE Begin Choledoc Clip (40mm): 2 pieces £190.00
CEV-567 MICROFRANCE Begin Intestinal Clip (50mm): 2 pieces £190.00
All prices exclude carriage and VAT and all are distributed by SIGH Ltd.
It is always useful to have a disposable fan retractor available. We have found Autosuture EndoRetract II (Catalogue No. 176613) useful to hold troublesom small bowel out of the pelvis or provide counter pressure on a rectum or spleen et.
MicroFrance Make a similar but re-usable product CEV415 (see below).
One area where a fan retractors is particularly useful is in conducting a laparoscopic adhesiolysis as seen here.
The fan is held in the left hand and used to hold small bowel in the pelvis and provide some countertraction for sharp scissor adhesiolysis.
5mm Peanut Dissectors
BLA find 40cm Endo-peanut 5mm blunt tip dissectors (BTD05) very useful for blunt dissection. They come packed in 3 and in boxes of 12.