Female Pelvic Surgery

2. Instrumentation for Female Pelvic Surgery

Stephan Seklehner Melissa A. Laudano  and Richard Lee 

(1)

Department of Urology, Weill Medical College of Cornell University, New York, NY, USA

Stephan Seklehner

Email: St.seklehner@gmx.net

Melissa A. Laudano (Corresponding author)

Email: melissa.laudano@gmail.com

Richard Lee (Corresponding author)

Email: Ril9010@med.cornell.edu

Introduction

Vaginal surgery requires proper instrumentation for success. The following instruments represent only a sampling of all that are available but which we have found most useful for female pelvic surgery. A picture as well as a brief description of each instrument has been provided. For a full listing, see Table 2.1.

Table 2.1

List of instruments and devices for female pelvic surgery

Open surgery

Catheters

Diluted indigo carmine solution

Yellofin® Stirrups (Allen Medical Systems, Hill-Rom Company, Batesville, IN)

Cystoscope

Weighted vaginal speculum

Uterine tenaculum

Allis forceps

DeBakey forceps

Metzenbaum scissors

Mayo scissors

Deaver retractor

Vaginal handheld retractors

Self-retaining retractors

Stamey needle

Raz double-pronged needle

Heaney needle holder

Capio device

Phaneuf clamp

Surgical sutures

Vaginal packing

Laparoscopic surgery

Veress needle

Laparoscopic trocars

Ligasure (Covidien, Dublin, Ireland)

Harmonic® scalpel (Ethicon Endo-Surgery, Inc., Johnson & Johnson, New Brunswick, NJ)

Laparoscopic forceps

Laparoscopic scissors

Robotic surgery (Da Vinci® Surgical System) (Intuitive Surgical, Inc., Sunnyvale, CA)

Monopolar scissors

Bipolar cautery

Dissectors

Forceps

Needle drivers

Instruments Used for Open/Vaginal Surgery

Uterine Tenaculum (Fig. 2.1)

Tenacula are useful instruments for grasping and holding tissue. The piercing hooks of a tenaculum can be anchored onto areas such as the cervix. The term tenaculum is derived from the Latin word “tenere” which means “to hold or grasp.” Uterine tenacula can be made of stainless steel, which makes them reusable after sterilization, or of plastic as disposable devices.

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Fig. 2.1

Uterine tenaculum

Allis Forceps (Fig. 2.2)

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Fig. 2.2

Allis forceps

Allis forceps are instruments designed to grasp and hold structures in atraumatic fashion. Their serrated jaws contain an atraumatic tooth-like structure, which enables the surgeon to hold on to delicate structures. Both self-locking and non-self-locking forceps are available according to the surgeon’s preference.

DeBakey Forceps (Fig. 2.3)

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Fig. 2.3

DeBakey forceps

DeBakey forceps are atraumatic forceps meant to grasp delicate tissue. The inner aspect of the tips contains microscopic, atraumatic teeth while the outer side of the instrument is normally ridged providing a better grip while handling with delicate structures. DeBakey forceps are normally straight with curved variants available for special utilization. Size can range up to 9.5 in.

Metzenbaum Scissors (Fig. 2.4)

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Fig. 2.4

Metzenbaum scissors

Metzenbaum scissors are named after the American surgeon who first designed the instrument. Mostly known as dissecting scissor, it is an excellent tool to perform fine cuts. Models with tungsten carbide cutting edges are the most precise while cheaper models are made of stainless steel. Regardless if the blades are curved or straight, if small (4.5 in.) or large (14 in.), they typically possess a long shank or handle with a blunt-tipped scissor sorter blades. Metzenbaum scissors should not be used to cut regular sutures as they can be dulled easily.

Mayo Scissors (Fig. 2.5)

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Fig. 2.5

Mayo scissors

In contrast to the Metzenbaum scissor, the Mayo scissor, named after the Mayo Clinic where it was invented, is designed to cut tougher structures. It can be used for dissecting but it is not as precise as Metzenbaum scissor. Mayo scissors can have either straight or curved blades, although they typically have semi-blunt ends. Straight-bladed Mayo scissors are also called “suture scissors” as they are amenable to cutting sutures since they do not dull as easily as other types of scissors. Curved Mayo scissors are usually used for cutting deeper thick tissue like the uterus as they allow deeper penetration into the wound. Mayo scissors can be made of titanium or stainless steel and normally range from 6 to 6 ¾ inches.

Deaver Retractor (Fig. 2.6)

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Fig. 2.6

Deaver retractors

Deaver retractors are flat, thin devices with curved ends. Models can vary according to length, width, and angel of curvature. The edges of the Deaver retractor are smoothed to avoid harm to surrounding tissue.

Vaginal Handheld Retractors (Fig. 2.7a, b)

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Fig. 2.7

Vaginal handheld retractors

Normally, vaginal retractors consist of a handle and a curved blade with varying lengths, widths, and angles. One of the most commonly used retractors is the Breisky–Navratil retractor, which has a ridged handle and a notch for good retraction and comfortable handling. Lighted vaginal retractors, like the Heaney–Simon or the Miyazaki retractors, have also been proposed for use in the deep pelvic surgery.

Self-Retaining Retractors (Fig. 2.8)

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Fig. 2.8

Self-retaining retractor (Cooper surgical, Trumball, CT)

The Scott retractor is a self-retaining retractor commonly used in vaginal surgery. Multiple piercing or non-piercing hooks can be used to optimize exposure of the surgical field. It can be used in tandem with a weighted vaginal speculum to maximize visualization during vaginal surgery.

Weighted Vaginal Speculum (Fig. 2.9)

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Fig. 2.9

Weighted vaginal speculum

A weighted vaginal speculum contains a weight at one end, utilizing gravity to help retract the posterior aspect of the vagina. Two main types of weighted specula exist: the traditional and the articulated device. Traditional specula have a rounded heavy end and a hollow groove which is positioned at a 90° angle to the blade of the retractor. Articulated specula can be adjusted by altering angles and lengths and can be made of plastic as well. There are several types of weighted specula, such as the Hardy-Duddy, Auvard, or Steiner variants.

Stamey Needle

The Stamey needle is a reusable special needle, with which sutures can be pulled from a vaginal incision into the suprapubic area. This needle can be needed for bladder suspension surgery.

Raz Double-Pronged Needle (Fig. 2.10)

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Fig. 2.10

Raz double-pronged needle

This device is a double-pronged ligature carrier, which can be used for bladder neck suspension or sling placement. The tip of the needle is placed under finger guidance to the desired position. The inner segment of the device can be slid over the external support, extending the tip of the needle to place the suture in the desired position.

Heaney Needle Holder (Fig. 2.11)

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Fig. 2.11

Heaney needle holder

The Heaney needle holder is a curved needle holder, which can be useful in situations where the use of a straight needle holder is difficult due to nearby anatomic structures.

Capio® Device (Fig. 2.12)

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Fig. 2.12

Capio® device (Bard Medical, Covington, GA)

The Capio® (Bard Medical, Covingon, GA) device is designed to throw, catch, and retrieve sutures. It is supposed to extend the surgeon’s reach into deep areas while ensure precise suture placement in difficult-to-reach areas. It consists of a head that can be angled, a needle driver component, as well as alignment indicator.

Phaneuf Clamp (Fig. 2.13)

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Fig. 2.13

Phaneuf clamp

The Phaneuf clamp can either be straight or curved-bladed. With single teeth at its blunt tip and serrated inner blades, it represents a solid instrument to clamp bigger and thicker structures like the cardinal, uterosacral, and broad ligaments during hysterectomy.

Cystoscope (Fig. 2.14)

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Fig. 2.14

Cystoscope

Urethrocystoscopy is an endoscopic procedure of the urethra and the bladder performed with a cystoscope. Cystoscopy is a routinely performed diagnostic as well as therapeutic procedure and can be done with flexible or rigid devices. Most cystoscopes have one or two ports allowing delicate instruments to be inserted like forceps or ureteral stents.

Catheters (Fig. 2.15)

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Fig. 2.15

Catheter

Indwelling urinary catheters are commonly used during surgery and in the perioperative period in order to guarantee emptying of the urinary bladder. Catheters can be made of many different types of material with silicone being most common. The size of catheters is measured in Charrière (in English speaking countries the term “French” is mostly used), with one Charrière being approximately 0.3 mm.

Diluted Indigo Carmine Solution

Diluted indigo carmine solution is primarily excreted by the kidneys within a few minutes after intravenous injection. The blue color can be very useful during surgery either to evaluate the exact position of the orifices under cystoscopy or simply to ensure the integrity of the bladder.

Surgical Sutures

Two main types of surgical sutures exist in terms of durability: absorbable and nonabsorbable. Surgical sutures may come in monofilament vs. braided (woven) forms. Suture sizes can range from 11-O to 7 as defined by the United States Pharmacopeia (USP).

Yellofin® Stirrups (Fig. 2.16)

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Fig. 2.16

Yellofin® stirrup (Allen Medical Systems, Hill-Rom Company, Batesville, IN)

Yellofin® stirrups (Allen Medical Systems, Hill-Rom Company, Batesville, IN) are used to hold legs in position while surgery is performed. The fin design of the boot reduces the likelihood of peroneal nerve injury, which might occur otherwise if the patient is not positioned in a proper way.

Vaginal Packing

Vaginal packing typically refers to cotton-woven gauze placed into the vagina to absorb bleeding and to provide pressure for tamponade.

Instruments Used for Laparoscopic Procedures

Veress Needle and Laparoscopic Trocars (Fig. 2.17)

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Fig. 2.17

Laparoscopic trocars

Instruments for laparoscopy are introduced into the body via trocars. Although blunt trocars exist, most possess a sharp tip to penetrate tissue. Most trocars have two openings: a primary port for inserting devices into the body and a secondary gas port. Trocars come in different sizes (e.g., 5 French for laparoscopic forceps, 10 or 12 French for cameras and larger instruments) and lengths. Trocars may be reusable or disposable.

It is possible to place the trocars under direct vision (Hassan technique) or blindly. If a blind technique is to be utilized, the desired surgical field should be first insufflated with gas. A Veress needle can be used to first penetrate the skin and underlying tissues to gain access to the desired surgical compartment. Gas is insufflated through the hollow core of the needle, after which the needle is removed and the trocar inserted.

Ligasure (Fig. 2.18)

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Fig. 2.18

Ligasure (Covidien, Dublin, Ireland)

LigaSure (Covidien, Dublin, Ireland) is an electrothermal bipolar tissue sealing system, which can be used for both open and laparoscopic procedures. It provides a combination of pressure and energy to seal and cauterize blood vessels and tissue. Vessels up to and including 7 mm in diameter as well as tissue bundles can be fused permanently without dissection or isolation. The seals can withstand up to three times normal systolic blood pressure. In contrast to ultrasonic devices, the LigaSure device is able to coagulate larger vessels and tissue structures but at the cost of a larger device size.

Harmonic® Scalpel (Fig. 2.19)

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Fig. 2.19

Harmonic® scalpel (Ethicon Endo-Surgery, Inc., Johnson & Johnson, New Brunswick, NJ)

In contrast to the Ligasure™ device, the so-called Harmonic® scalpel (Ethicon Endo-Surgery, Inc., Johnson & Johnson, New Brunswick, NJ) is a cutting and sealing instrument using ultrasound vibratory energy. It is often used in laparoscopic procedures, as it can be directed to either cut tissue (by vibrating in the range of 55.5 kHz) or to coagulate smaller vessels and tissue by sealing them through protein denaturization.

Laparoscopic Maryland Forceps and Laparoscopic Scissors (Fig. 2.20)

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Fig. 2.20

Laparoscopic scissors

The Maryland forceps has a 10 mm diameter and has a 33 cm length (with up to 45 cm available on request). With is serrated semi-blunt tip, which can be rotated by 360° at the handle, it can be used to grab and secure tissue. Additionally, tissue can be cauterized using electrocautery. As with laparoscopic forceps, the laparoscopic scissors can also be rotated and used to cauterize tissue.

Instruments Used for Robotic Surgery: Da Vinci® Surgical System (Figs. 2.212.222.232.24, and 2.25 a, b)

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Fig. 2.21

Da Vinci® robot (Intuitive Surgical, Inc., Sunnyvale, CA)

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Fig. 2.22

(a) Da Vinci® robot needle driver. (b) Tip of Da Vinci® robot needle driver (Intuitive Surgical, Inc., Sunnyvale, CA)

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Fig. 2.23

(a) Da Vinci® robot precise bipolar forceps. (b) Tip of Da Vinci® robot precise bipolar forceps (Intuitive Surgical, Inc., Sunnyvale, CA)

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Fig. 2.24

(a). Da Vinci® robot prograsp forceps. (b) Tip of Da Vinci® robot prograsp forceps (Intuitive Surgical, Inc., Sunnyvale, CA)

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Fig. 2.25

(a) Da Vinci® robot curved scissors. (b) Tip of Da Vinci® robot curved scissors (Intuitive Surgical, Inc., Sunnyvale, CA)

The da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) has been approved by the Food and Drug Administration (FDA) for gynecologic laparoscopic surgical procedures. The system consists of a patient-side cart with, depending on the model, three or four robotic arms, and an accompanying command console. While one robotic arm is utilized for the endoscopic camera, which enables full stereoscopic vision for the surgeon, the other arms are used to manipulate laparoscopic instruments. The robotic arms can be moved with hand controllers and foot pedals. One of the advantages of the Da Vinci® Surgical System is that it has been designed to maximize flexibility of movements and to minimize human tremor.