A useful guide to instrumentation and equiment, the essentials, as well as instruments for more advanced surgeons and procedures

Please note that these comments are a review rather than endorcement of any particular equipment, instruments, or manufacturers.

It goes without saying that it is sensible to buy the best equipment one can afford, but in the harsh financial practicalities of veterinary practice, some compromise, will almost certainly be needed. What elements could you compromise safely with the least effects on surgical safety, ease of use, and equipment lifespan? The most critical equipment, on which one should aim to compromise the least, are the components involved in generating the image (laparoscope, camera and processor, light source and light cable). An unsuitable light cable and resultant poor surgery visualisation will have a far greater impact on surgery than having only a limited number of instruments. It is also far more costly to replace a poor quality camera system or light source, than to gradual add individual instruments to a kit.

 

The laparoscope
The most suitable general purpose laparoscope for canines is a 5mm 30 degree 30cm length laparoscope. This is the most suitable balance between small diameter, adequate light transmission, and reasonable image size. For very small dogs and cats a 3mm 30 degree laparoscope is also suitable, but transmits less light. Human general surgeons commonly use a 10mm diameter 30 degree laparoscope which results in a larger picture and greater light transmission, advantageous in large adult human abdomens. 0 degree ofset laparoscopes are also favoured by some surgeon for ease of orientation initially. Some veterinary surgeons like to use operating laparoscopes to perfrom single port laparoscopic ovariectomies in dogs (below a 5mm, 10mm operating and 10, standard laparoscope - all are 0 degree laparoscopes).

 
Reusable, disposable, and reposable ports and instruments
There are tends in some countries such as North America to use more disposable ports and instruments in human surgery, this is due to the cost and time involved in reprocessing instruments, as well as perceived increased risk of disease transmission. Disposable ports and instruments are not environmentally friendly, and are also generally poor value for money in veterinary practice, with some disposable ports costing about £80 each! Good quality re-usable ports and instruments if well cared for and properly cleaned are reliable and most cost effective for veterinary practice. Some manufacturers also produce reposable ports. These are re-usable ports, but have a single use valve that is replaced after a procedure. These reduced crevices that are difficult to clean in completely re-usable ports.
 
 
Reposable 3mm, 5mm, 10mm, 11mm, and 12mm ports (YelloPort, Surgical Innovation). The ports and trocars are re-usable, with a single use sterile lubricated silicon valve as the only disposable portion, which reduces the difficulty of cleaning and sterilisation. This reduces the cost and also contributes to less land-fill and lower environmental impact than disposable ports. The trocar on the right has a rounded pencil point tip, instead of a sharp point, and is lss likely to injury underlying structures.
 
 
Many reusable cannulas may be difficult or time consuming to clean and sterilise safely, such as this traditional trumpet valve cannula.
 
   
Disposable cannulas such as these Endopath and Xcel cannulas (Ethicon endo-surgery) are convenient and need no cleaning and are increasingly popular in human laparoscopic surgery in some countries, but have the disadvantage for veterinary laparoscpy of significantly raising an procedures expense, can not be safely cleaned and reused, and are also not particularly environmentaly friendly, contributing to increased landfill.

Safe laproscopic access to the abdomen
Safe access to the abdomen is perhaps the most difficult part of any laparoscopic procedure, and no matter how much care is taken, and whatever technique used, injuries to underlying abdominal structures can occur. It is also a contentious area of both humana nd veterinary laparoscopic surgery, with different surgeons having very strong opinions on their preferred technique. Despite differing opinions, a large Cochrane review of human laparoscopy studies did not demonstrate that veress needle use was more dangerous than open approach access, which is currently in favour by general surgeons in the UK.

Blind approach using the veress needle
Blind sharp trocar entry using prior insufflation of the abdomen with a special guarded double lumen needle (originally designed for thoracocentesis in humans with tuberculosis), is still the most commonly employed access technique by veterinary surgeons, and is also still popular with gynaecologists. The technique has fallen out of favour with general surgeons in the UK, and open access is generally taught to surgery residents due to the lower risk of major vascular trauma. The spleen of carnivores is much larger than in humans and is at increased risk of trauma by the verres needle. Even if haemorrhage is minor and self limiting, relatively small amounts of haemorrhage do obscure vision, and interfere with optimal visualisation, and may require suction and lavage, increasing operative time. There is also the risk of gas embolism if the veress needle punctures the spleen or major vessel. Different authors recommend different sites, such as umbilical right lower quadrant, and the right upper quadrant, just below the costal arch. The needle usually gives a distinctive double click once it enters the peritoneal cavity, and pressure should rise slowly on initial insifflation. A rapid increase in pressure when insufflation is started indicates the needle is inside tissue or has not actually entered the abdominal cavity.

     

A reusable sharp trocar, it is clear that this can inadvertatly seriously traumatise underlying organs on blind entry. Sheathed cutting trocars (Xcel, Ethicon endo-surgery) are similar in principle to a verress nedle, with a retractable blade, and hence safer, but can still result in inadvertant visceral trauma.

Open access
Open access is the method of entry currently favoured by most general surgeons in the UK, and is regarded as the safest method, although systematic reviews have not demonstrated this conclusively. An incision is made through the caudal portion of the umbilical scar (as the abdominal wall is thinnest at this point. By means of retraction and careful blunt and sharp dissection with artery forceps or small scissors, the abdominal cavity is entered. The primary (optical) trocar is inserted with a blunt trocar. In many cases the seal is sufficiently tight to prevent any gas leakage, but in larger or obese patients a conical Hasson cannula can be used to seal any gap and maintain a pneumoperitoneum. This is the authors method of choice in dogs, cats, and small pet mammals.  A flexible ring retractor (Lonestar) has a low profile and is perfect fo retraction for open access when performing minor laparoscopic procedures (such as liver biopsy) without an assistant. Videos of the open approach in dogs and other animals can be seen on the surgery videos page.

Using a "Lonestar retractor" (Ark Surgical) to help with an open approach placement of the primary cannula in laparoscopic surgery in a Reindeer. This controlled entry avoids the risk associated with a verress needle, and blind placement of the primary trocar. While the use of a verress needle as traditionally been used in veterinary laparoscopy, human general surgeons are now increasingly favouring an open approach for its safety, and we believe this is an important alternative to consider in veterinary patients.

 

Ethicon endo-surgery produces a disposable blunt trocar and cannula and Hassons conical cannula for open approach placement of the primary (optical) cannula, but these are not ideally suited to veterinary use, due to their high cost and single use nature, which increase procedure costs to the client considerably, as well as the detrimental environmental footprint of increasing plastic in landfills.

Optical controlled access
Optical trocars may also be used for visually controlled access to the abdomen. The Visiport (Covidein) trocar is designed for a 10mm 0 degree laparoscope and is a single use disposable instrument, and hence is not commonly used in small animal laparoscopy. It has a trigger that fires a 1mm depth blade for controlled access into the abdomen, and may be used in the non-insufflated abdomen as well. The Ternamian EndoTip (Karl Storz) is a steel reusable cannula, and is popular with some vets. It is available in 10mm, 5mm, and 3.9mm sizes. It is only suitable for use in the insufflated abdomen, so does not eliminate the risks associated with a veress needles use, but is an improvement of a sharp trocar. It must be used with a 0 degree laparoscope. It is not safe to use in a non-insufflated abdomen.

  

Ternamian EndoTip reusable 10mm and 5mm optical trocars. These trocars need a 0degree laparoscope for optical control of entry. Puncture of the large intestine in a guinea pig caused by a Ternamian trocar. No entry method is without its risks.

Visiport (Covidien)optical cutting access port. This is a visual access port, with a triggered 1mm cutting blade, the tissue planes incised are visualised via the endoscope through the clear distal window. It was originally marketed for use after blind insufflation with a verres needle, but several human studies have demonstrated its safe use for primary access without prior insufflation. The video demonstrates the view through a 11mm Covidien "Visiport" during primary access in a giraffe without prior insufflation. (R Pizzi).

 

Xcel (Ethicon endo-surgery) conical non-cutting rocars can be used under optical control and do not cut tissue, but the sharp wings  seperate tissues, and hence smaller trocar wounds do not need suturing and reduce the risk of post-operative wound hernias developing. As with all disposable cannulas these are not ideally suited to veterinary use, due to their high cost,  as well as the detrimental environmental footprint of increasing plastic in landfills, which should always be considered by ethically minded veterinary surgeons.

Monopolar Surgical Instruments 
Monopolar instruments pose very specific risks in laparoscopic surgery (see surgical techniques for more details). While monopolar electrosurgery instruments such as monopolar hooks are commonly used in human laparoscopic procedures, such as laparoscopic cholecystectomy, they are not well suited to many common veterinary procedures, such as ovariectomy. They also carry a higher risk of severe burns at the contact (ground) plate, as animals such as dogs, cats, and rabbits, with their lighter body weight and dense fur are at an even higher risk of poor plate contact than humans, and special care really must be taken. These risks can be reduced by the use of higher frequency current - so called radiosurgery (Surgitron, Ellman). More advanced veterinary laparoscopic procedure may require monopolar surgery as a modality, and a good understanding of its principles is given in an excellent video tutorial, as well as in the surgical techniques section.

  

A monopolar surgical hook, commonly used in human laparoscopic surgery for laparoscopic cholecystetomy (a video of a monopolar hooks use in a ferret can be seen on the surgery videos page). Cracked or damaged insulation will result in out of sight electrothermal injuries to non-target organs, and insulated cannulas provide a risk of acting as capacitors when used with monopolar surgery.

Coming soon - reviews of other laparoscopic instruments and equipment...

Laparoscopic staplers
Laparoscopic stapling equipment is some of the most expensive laparoscopic consumable items that a veterinary surgeon may consider purchasing. While almost essential in some situations, in other scenarios while stapling may save time in surgery, it may on balancing this versus increased procedure costs, make more sense to pursue another technique, such as a laparoscopic-assisted procedure, extracorporeal suturing or ligation, or even intracorporeal suturing. Some modern electrosurgical modalities such as tissue feedback bipolar surgery or an ultrasonic scalpel will also provide an alternative "tissue sealing" and sectioning method.

These laparoscopic staplers produce 2-3 lins of staples on either side of tissue, as well as cutting between these staple lines. Different lengths (30mm, 45mm, 60mm) and different staple sizes (2.0-4.8mm) are suited to different tissue thickness and procedures. They are most commonly used in human gastrointestinal surgery and horacoscopic or video-assisted thoracic lung surgery. Colorectal neoplasia and gastric bypass bariatric surgery are not commonly perfromed in small animals, and enterotomy/enterectomy may also be perfromed as a laparoscopic assisted procedure, which is quicker surgery, and still minimally invasive, in preference to using stapling devices in a completely laparoscopic procedure.

 

Ethicon endo-surgery ETS staplers (above) provide excellent staple security, with a sturdy steel anvil as part of the handpiece, and are favoured by many human colorectal surgeons for this reason. The main disadvantage for veterinary surgeons is that despite reloads being available, the cutting blade is actually in the handpiece, and while very good quality, this will become blunt after several firings, requiring a new handpiece and increasing a procedures expense dramatically. Reloads are also limited to the same cartridge length as the handpiece (30mm, 45mm, or 60mm), but different staple lengths can be used with reloads (for differing tissue thickness).

 

The Endo GIA stapler from Covidien (above) is more suited to veterinary use. The universal handpiece can be reused with care a large number of times (if kept from gross blood contamination, and resterilised with ethylene oxide). Individual staple cartridges are more expensive than those of the ethicon stapler, but each reload contains its own anvil and blade. Straight and rotating (roticulator) cartridges of differing length can all be used with the same universal handpiece. The anvil is less sturdy than the ethicon stapler, and the blade also appears slightly more prone to incomplete sectioning of tissue pedicles on occasion. Care must be taken to select the correct staple cartridge for tissue thickness to prevent incomplete sectioning.

Retractors
Retraction of intra-abdominal structures is much more limited in comparison to open surgery, where one can simply "grab something and shove it to the side". Small animal veterinary laparoscopic surgeons are fortunate that dogs are laterally flattened and by tilting the patient from side to side in dorsal recumbency, one can cause organs to flop to the side, and out of the way. Many veterinary surgeons perform laparoscopic ovariectomies with midline ports sites, but with the patient practically in lateral recumbency to keep organs retracted adequately from the ovarian pedicle. In some cases however, things are not so simple. Performing a laparoscopic cholecystectomy for a biliary mucocoele, examining adrenal glands, or some intra-thoracic surgery, for example, may all require the use of a retractor to adequate perform a procedure. Fan retractors are the most commonly available retractors, but usually are 10mm in diameter, needing a larger port, and also risk traumatising friable structures such as the liver when closing the blades, or simply on the edges which may become sharp over time. While flexible 5mm retractors are more expensive these are much less traumatic, and easier to use as a "paddle" to position structures out of the way.

 

An example of an atraumatic 5mm flexible retractor (Diamond-flex, Surgical Innovations). Different retractor patterns are available.

  

Use of a 3mm flexible retractor (Diamond-flex, Surgical Innovations) to retract the spleen in a pet ferret for laparoscopic removal of an ovarian remnant. On the right, use of a 5mm retractor to move the caudal rumen and create space in the caudal abdomen of a ruminant.

The basic laparoscopy stack:
• Camera processor and camera head
• Light source and light cable
• Insufflation unit and tubing
• Screen/TV
Also recommended:
• Video recorder
• Electrosurgery unit
• Suction unit and tubing

As an alternative, a portable self-contained screen, light source and camera unit may be used, such as the Karl Storz Telepack. While the portability is a useful asset, there is of course a compromise in light source (metal halide light rather than Xenon) and one is limited to the use of a single chip camera. A seperate insufflator and electrosurgery unit are still needed.

A sterile laparotomy instrument set should always be available in case of the need for conversion to open surgery due to a complication.

Some examples of reusable laparoscopic surgery sets:

2-port laparoscopic ovariectomy example instrument list
• 10mm port and blunt trocar
• 5mm port
• Reducer tube (10-5mm)
• Traumatic grasper
• Scissors
• Bipolar forceps
• Large ½ circle cutting suture needle

Laparoscopic-assisted cryptorchidectomy example instrument list
• 2 x 5mm port and single blunt trocar
• Reducer tube (10-5mm)
• Traumatic grasper forceps
• No 13 scalpel blade (or fascia cutter)

Basic re-usable general laparoscopic surgery instrument list
(suitable for exploratory laparoscopy)
• 3 x 5mm ports
• 1 x 5mm blunt trocar
• 1 x 5mm sharp trocar
• 1 x 10mm or 12mm port
• 5mm Palpation probe
• 5mm biopsy forceps (cup)
• 2 x 5mm atraumatic bowel forceps
• 1 x 5mm toothed (traumatic) grasper forceps
• 1 x 5mm curved Kelly dissecting forceps
• 1 x 5mm curved scissors
• 5mm Bipolar forceps
• 5mm monopolar L-hook
• 5mm needle holder
• 5mm knot pusher
• 5mm flexible retractor or 10mm fan retractor

Reusable 3mm paediatric instruments are suitable for small dogs, cats, and exotic animal species, and almost as wide range of different instruments is available as in 5mm diameter size.

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While we do try our best and make every reasonable effort to ensure that the details on this website are correct, the information on this website is in the nature of opinionated review and the view expressed here are not necissarily those of the website moderators,  owners, or sponsors.
The site moderators can not be held responsible in anyway for any omissions, errors, or differences of opinion, and any losses or damages that may be incurred directly or indirectly as a result. It is the responsibility of visitors to consult their own veterinarians for any matters related to there animals health, and the responsibility of veterinarians to use the information presented here in a responsible and legal manner. It is every veterinary surgeons responsibility not to attempt to perform surgical procedures beyond their level of experience or expertese, and to undertake further training, continuing proffesional development (CPD), and consult with experienced or specialist veterinary surgeons.