Selection of surgical instruments for single port laparoscopic gynecology
Gynecological single port laparoscopic surgery includes two ways: transumbilical or transvaginal. They are respectively through the umbilical 2~3cm incision or transvaginal single port insertion of the endoscope and instruments to complete the surgical operation. The interference between the body and even the optical fiber is very serious. In order to make surgical operations more convenient and efficient, equipment manufacturers continue to improve surgical equipment, including camera systems, operating platforms (Port), conventional operating equipment, and energy equipment, under the strong demand of doctors. They have made great progress in recent years. This article reviews the improvements and applications of these systems and devices in mainland China.
1、Improvement of camera system
Porous laparoscopic surgery mostly uses a 10mm diameter lens. When a 10mm lens is used for a single port laparoscopic surgery, the cross-sectional area of the single port channel occupied by the lens body is 5 times that of a 5mm diameter lens, so a longer 5mm lens came into being. This improvement not only greatly reduces the single-hole channel space occupied by the mirror body, but also greatly reduces the obstruction of the optical fiber and the mirror holder to the operator's handle. In addition, the use of the optical fiber rotation angle makes the optical fiber run parallel to the longitudinal axis of the lens body to the camera, avoiding the influence of the optical fiber perpendicular to the lens body on the surgical operation. The 3D camera system introduced a few years ago has a significantly reduced camera head, and the optical fiber and camera data line are in the same axis as the mirror body. It has great advantages for single-port laparoscopic surgery. In addition to further reducing the obstacle to the operator, The 3D image greatly enhances the surgeon’s spatial position experience, making the surgeon’s operation more precise, safer and faster; among them, the 30° lens is more beneficial, the lens body and the axis of the operating instrument appear at an angle, and the lens body and camera face the surgeon. The obstruction of the operating handle is further reduced.
2、Evolution of the operating platform
Single-port laparoscopic surgery first used a rigid fixed platform made of metal or plastic. Later, a fixed platform consisting of an incision protective sleeve and an operating platform was used. These platforms are not only relatively expensive, but also unable to adjust the positional relationship between the lens and the operating equipment during the operation, which gradually fades out of people's field of vision, and only a few are still sold and used in certain areas. Later, based on the concept of the split platform, the doctors made their own "incision protection sleeve + gloves" operating platform. Gynecological single-port laparoscopic surgery has been well developed, and the types, numbers, and units of surgery have increased significantly. On the one hand, the self-made platform is very cheap, and the increase in medical costs, patients and medical insurance burdens is small; on the other hand, because the operating instruments and lens positions are more convenient to change, the surgical operation is easier and faster; some doctors still have different degrees of improvement. Obtained some utility model patents. However, the self-made platform is not very formal after all. The emergence of new rotatable and flexible split platform products, as well as multi-level meetings, training courses and experts vigorously promote the concept and technology of gynecological single-port laparoscopic surgery, giving the gynecological single-port abdominal cavity The development of endoscopic surgery has injected new vitality, and more and more young gynecological scholars have joined the ranks of gynecological single-port laparoscopic surgery. The rotatable flexible split platform is widely used and is still being improved. In addition to the operation equipment and lens position conversion, and the operation is more convenient and quick, the use of the incision protection sleeve can effectively prevent the contamination of the incision and benign and malignant tumors when the specimen is taken out. The incision planting, coupled with a special smoke exhaust channel, can greatly reduce the interference of the tissue debris from electrocoagulation, electrocutting smoke and ultrasonic knife atomization during the operation on the surgical field of vision. The incision protective sleeve with the vaginal support ring makes the The rapid development of vaginal gynecological laparoscopic surgery. In 2018, a new type of single-port operation platform suitable for robotic laparoscopic surgery was introduced to mainland China, and robotic gynecological single-port laparoscopic surgery started and developed. In addition, some single-port operation platforms different from the above-mentioned platforms have also appeared one after another, such as pneumoperitoneum single-port platform, single-incision fascia platform, transumbilical multi-incision approach, etc., contributing to the continuous development of gynecological single-port laparoscopic surgery The role of.
3、Improvement of common operating equipment
Gynecological single port laparoscopic surgery is almost always used for multi-port laparoscopic surgery. The mutual interference between the instruments, the instruments and the mirror body, and the absence of the operating triangle give rise to turning and lengthening operating instruments. Turning operation instruments are gradually eliminated due to the difficulty of manufacturing, fragile and difficult maintenance, and the unaccustomed and unsuitable operation operators. The lengthened non-turning operating instruments are matched with the conventional length operating instruments, which reduces the mutual obstruction between the operating handles and the mutual interference with the mirror body, and the extended non-turning instruments can also be used for porous laparoscopic surgery, which helps to reduce The purchase cost of the instrument has been retained. Commonly extended operating instruments include grasping forceps, separating forceps, unipolar electric hooks, needle holders, irrigators, and so on.
4、Improvement of energy equipment
The improvement of energy equipment seems to be relatively slow, difficult, and has a long cycle. In laparoscopic surgery, especially single port laparoscopic surgery, frequent replacement of energy devices is a headache. Energy devices with good separation, cutting, and coagulation and closure effects are rare. The unipolar electrosurgical cutting effect is good, and the coagulation efficiency is not good, and the blood vessels below 2mm in diameter can barely coagulate. Most bipolar coagulation has only coagulation closure function and cannot cut. Smart bipolars such as safety knife, ligation speed and encyclopedia scissors seem to have the three functions of separation, cutting and coagulation closure, but each has its own advantages and disadvantages; In single-port laparoscopic surgery, each has its own limitations due to factors such as the length, diameter, and volume of the handle. The existing ultrasonic knives have good separation and cutting capabilities, and the effect of coagulation and closure of large blood vessels is not as good as that of bipolar electrocoagulation instruments, even ultrasonic knives with bipolar electrocoagulation functions. So far, there are two types of energy instruments that have been improved specifically for single-port laparoscopic surgery: the extended ultrasonic knife and the turnable ENSEL instrument. Turnable ENSEL has a turning function of the tip end. The curvature can be adjusted according to the needs during the operation. The operation is more convenient, and the tissue can be clamped, closed and cut at a better angle. The extended ultrasonic knife adopts the second-generation intelligent tissue sensing technology (ATT2), which can reliably coagulate and close blood vessels with a diameter of 7mm and below, which is comparable to the blood vessel closure effect of bipolar coagulation. The length of the knife shaft is increased by 9cm to 45cm. It can effectively avoid mutual interference and obstruction between instruments in surgical operations, so it is an energy instrument that is very suitable for single-port laparoscopic surgery. In short, with the continuous improvement of various instruments, the continuous simplicity of operation and the continuous improvement of reliability, gynecological single port laparoscopic surgery will be more and more accepted by the majority of gynecologists and patients, and thus will be better developed.