Advances in Abdominal Surgery Instrumentation

Patient Safety General Surgery

By: Sharona Ross, MD, FACS

Published: 12/7/2021

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A variety of modalities that cut and coagulate tissue make procedures easier for surgeons and safer for patients.


Several years ago, a 96-year-old woman who was experiencing severe chest pain came to see me. She could no longer eat and explained that — for 40 years! — she had been repeatedly diagnosed with a paraesophageal hernia. Inexplicably, at no time was this woman told there were surgical interventions that could help her. Over the years, the untreated hernia caused her small bowel, stomach and spleen to move into her chest, taking the room her lungs and heart needed to function properly, which explained her shortness of breath and heart palpitations.

After a short hospital admission, we discharged her, put her on a liquid diet of protein shakes and scheduled her for surgery. The only reason she stayed overnight after the procedure was for observation. The single-incision laparoscopic procedure we performed with the use of modern instrumentation is routinely performed today on an outpatient basis on younger, healthy patients.

That case and thousands like it are made possible through the use of flexible laparoscopes and a combination of energy devices and modalities that allow surgeons to perform safe and efficient same-day surgeries that improve patient outcomes. Here’s a look at how the equipment works in practice and enhances a vast array of abdominal procedures. 

Maximum maneuverability

Deflectable laparoscopes allow surgeons to perform gallbladder procedures through a 1.2-cm single incision in the navel, which leaves no visible scars. Single-incision laparoscopy requires placing three to four ports through the same incision simultaneously: one is used for the laparoscope; the second for a 5mm grasper; the third is used for a second grasper; and the fourth is used for a hook cautery, the instrument that does the actual dissection. For that to work, surgeons must cross the instruments on the inside of the patient and a straight scope would limit their range of motion. Being able to use a laparoscope with a deflectable tip effectively removes the shaft of the scope from the rest of the instruments to eliminate clashing and allow surgeons to maneuver the laparoscope with a great range of motion. Surgeons can use flexible-tip laparoscopes to view the operative field from several angles and behind tissue without moving the instrument, a factor that allows them to perform safer surgery. 

Articulating laparoscopes also give surgeons more autonomy during surgery. The articulation in the shaft allows them to keep the handle away from the port and flat against the patient’s pelvis, where it can be anchored with a grasper to the surgical drape. An assistant or scrub tech can hold a retractor in a ready position. This set-up allows surgeons to perform the procedure with minimal assistance.
The newer scopes have 30- to 100-degree ranges of motion, capture ultra-high-def images and are fully autoclavable. Some scopes also provide enhanced imaging of blood vessels and other tissues, and eliminate the need for the surgeon to manually focus and refocus the instrument as it’s moved around the surgical field.

Cutting and sealing

FAR REACH Minimally invasive surgery using laparoscopes with flexible tips offers surgeons a range of motion that allows them to make precise cuts while minimizing damage to adjacent tissue.

Ultrasonic shears work very well on 7mm vessels and feature adaptive-tissue technology that adjusts the amount of energy delivered to the tips based on the thickness of tissue being grasped. Curved blades on these instruments are designed to improve visibility at the business end and the coated surfaces allow for quick and precise cutting. Ultrasonic shears are widely used to seal pulmonary vessels 7mm or smaller in procedures such as anti-reflux procedures, hiatal hernia repairs, foregut surgeries and multiple procedures on the esophagus, stomach and small bowel.

As is the case with most electrosurgery devices, there is always a risk of lateral thermal spread injuries when these graspers are used. Extended bursts of energy delivered through prolonged activation creates high temperatures at the instrument’s tip. If the procedure calls for immediately cutting another area of tissue, surgeons can quickly touch the tip to a piece of fat to cool it down so it’s safe for continued use. 

Many physicians prefer to work with a single instrument that integrates the ability to cut tissue with ultrasonic technology and seal blood vessels with ultrasonic energy or high-frequency bipolar electrical current. These devices save time and increase efficiency because surgeons don’t have to use harmonic scissors to make cuts and then switch to a sealing device to stop vessels from bleeding. The tips in these devices are designed for fine dissection, so they can be used for multiple roles in a procedure such as repairs of gastric vessels during hiatal or stomach hernia procedures.

Hybrid devices are powered by a single generator, and some offer the ability to use ultrasonic and bipolar energy simultaneously for quick and precise sealing and cutting. Some devices also feature intelligent tissue monitoring technology, which includes an auto-stop feature that cuts off the energy after satisfactory transection occurs to prevent patient injury.

Radiofrequency energy devices are indispensable tools for procedures in which vessels smaller than 1mm need resealing. They use heat-inducing technology that stops bleeding by shrinking collagen in blood vessels. The device I use combines radiofrequency energy and saline to provide hemostatic healing of soft tissue and bone. By operating at 100°C, about 200 degrees less than many other electrosurgery devices, it does the job while reducing the amount of surgical smoke emitted into the air.

These devices, which effectively abate bleeding from very small blood vessels, are used for liver resections, distal pancreatectomies, partial nephrectomies and colon procedures. Some monopolar sealers on the market are useful in this regard as well. Controlling this type of bleeding reduces hematomas, improves visualization at the operative site, can reduce the need for powder hemostatic agents and results in shorter surgeries. It can also reduce post-op pain and swelling, resulting in faster discharges. Reducing the potential need for blood transfusions during surgery limits the risk of complications, infections and hospital transfers.

Recipe for success

ROOM TO MOVE Laparoscopes with flexible tips allow surgeons to place the handles flat against the patient’s pelvis and out of the way of other instruments.  |  AdventHealth Tampa
Using these devices and energy modalities in combination leads to efficient and precise surgeries, which make for faster procedures, shorter recoveries and better outcomes for patients. Working with advanced instrumentation certainly factored into the case of my 96-year-old patient, whom I walked out of the hospital. She went on to thrive for several more years. She was an author of recipe books and wrote another one after her surgery. She was kind enough to send me a copy, which I still have and treasure. My experience caring for this woman proves patients shouldn’t endure debilitating pain and discomfort because they think the prospect of surgical interventions are too drastic. We can restore them to health and in many cases, they can recover at home on the day of surgery, thanks to instrumentation that continues to move minimally invasive techniques forward. OSM

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