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Rigid endoscopy and endosurgery: principles

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Abstract

Whereas the use of flexible endoscopes is largely confined to the gastrointestinal and respiratory tracts, where the ability to follow a tortuous lumen is paramount, rigid endoscopes can be introduced into any appropriate body orifice - and if a suitable orifice can't be found, then the surgeon can make one. Laparoscopy and thoracoscopy have challenged the traditional paradigms in human surgery and have revolutionized the treatment of many common conditions, such as gallbladder disease, reproductive tract disorders, bowel cancer and heart disease. This chapter examines Health and safety considerations; Anaesthetic considerations; Patient positioning; Insufflation; Choice of endoscope; Special considerations for endosurgery; Portal placement; Procedure; Dissection and haemostasis; Suction and irrigation; Specimen retrieval; Knot tying techniques; Closure; and Postoperative care.

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Figures

Image of 7.1
7.1 Port placement for triangulation in laparoscopy. X marks the site of surgical interest. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.2
7.2 Extracorporeal knot tied using Babcock forceps. The needle is passed down through the port and around the tissue to be ligated. The needle is then brought out of the port such that both ends of the suture material are outside the body. A single or double half hitch is tied as usual and the free ends of the suture are threaded through the holes in the jaws of the forceps from the inside to the outside. Slight tension is applied to the free ends. The knot is slid down into the abdomen with the jaws of the Babcock forceps closed. Once the knot is in place, opening the jaws of the Babcock forceps applies tension to the knot to cinch it down. The Babcock forceps are then gently withdrawn and one end of the suture unthreaded from the jaws. A second half hitch is formed, the Babcock forceps are rotated and the free end re-inserted through the jaws as before. The second throw is then pushed down into the abdomen and cinched tight as before. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.3
7.3 Roeder knot. This is formed by throwing a half hitch which is then held between the index finger and thumb of the left hand. The free end of the suture is then wrapped three times around the two limbs of the loop between the half hitch and the tissue to be ligated. This free end is then wrapped around just one limb of the loop and brought back through the last loop so created. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.4
7.4 Intracorporeal knot tying: direction of suture line. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.5
7.5 Applying tension around a pulley. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.6
7.6 Tying an intracorporeal square knot. With the needle passed through the tissue from right to left, the needle is brought back over to the right to form a ‘C’ loop. The grasping forceps are introduced over the suture material and into the loop from the left. The suture material is grasped by the needle holders and wrapped around the grasping forceps, which then grasp the free end of the suture to form the first half hitch as the instruments are drawn apart. The needle or long part of the suture material is then grasped again by the needle holders and brought over to the left to create a reverse ‘C’ loop. The suture material is then grasped by the grasping forceps and wrapped around the needle holders, which are advanced to grasp the free end and complete the second half hitch. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 7.7
7.7 Converting a square knot to a half hitch. With a loose square knot in place and the long end of the suture grasped in the left hand and the free end to the right, the suture material is grasped between the knot and the tissue on the same side as the long end, i.e. the left, and tension applied to the knot by moving the graspers and needle holders apart. This converts the knot to two half hitches. Maintaining tension with the graspers in the left hand, the needle holders can be placed above the knot and used to slide the knot down on to the tissue. Grasping the free end with the needle holders, and applying sharp tension to both ends of the suture, converts the knot back to a square knot for security; an additional throw can be formed. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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