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Principles of rigid endoscopy and endosurgery

image of Principles of rigid endoscopy and endosurgery
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Abstract

Whereas flexible endoscopes see most use in the gastrointestinal and respiratory tracts, rigid endoscopes can be introduced into any appropriate body orifice, or used for laparoscopy and thoracoscopy. This chapter covers health and safety considerations, anaesthetic considerations, patient positioning, choice of endoscope, port placement, dissection, haemostasis, suction, irrigation, specimen retrieval, knot-tying techniques, desufflation, closure and postoperative care.

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Figures

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8.1 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.
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8.2 Optimum ergonomic angles for instrument and endoscope placement.
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8.3 Voltage and waveforms for common monopolar electrosurgical settings.
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8.4 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) 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. (b) Slight tension is applied to the free ends. (c, d) The knot is slid down into the abdomen with the jaws of the Babcock forceps closed. 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. (c, d) The knot is slid down into the abdomen with the jaws of the Babcock forceps closed. (e) Once the knot is in place, opening the jaws of the Babcock forceps applies tension to the knot to cinch it down. (f, g) The Babcock forceps are then gently withdrawn and one end of the suture unthreaded from the jaws. (h) A second half hitch is formed, the Babcock forceps are rotated and the free end re-inserted through the jaws as before. (i) 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.
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8.5 Roeder knot. (a–d) This is formed by throwing a half hitch which is then held between the index finger and thumb of the left hand. (e) 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. (f) The 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.
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8.6 Intracorporeal knot tying: direction of the suture line. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.7 Applying tension around a pulley. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.8 Tying an intracorporeal square knot. (a) 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 receiving forceps are introduced over the suture material and into the loop from the left. (b–d) The suture material is grasped by the needle holders and held parallel to the receiving forceps, which are rotated clockwise around the loop and then used to grasp the free end of the suture to form the first throw as the instruments are drawn apart. (e) 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. (f–h) The suture material is then grasped by the receiving forceps and wrapped around the needle holders, which are rotated clockwise around the loop and then used to grasp the free end of the suture material to complete the second throw. If the suture material is short, the needle can be grasped such that the swaged end is held parallel to the instrument forming the throw; this provides a stable loop with which to work. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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8.9 Converting a square knot to a half hitch. (a) 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 is applied to the knot by moving the receiving forceps and needle holders apart. This converts the knot to two half hitches. (b, c) Maintaining tension with the receiving forceps in the left hand, the needle holders can be placed above the knot and used to slide the knot down on to the tissue. (d) Grasping the free end of the suture material 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 then be formed. Drawn by S. J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.

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