Surgical Instrumentation and Sutures
It is imperative that surgeons understand the choice and limitations of their instruments and sutures with regard to a planned surgery. This knowledge will often make the difference between struggling or proceeding with purpose. Keeping current on the rapid and ongoing development of instrument technology can be difficult for the busy clinician. Yet taking advantage of these innovations can contribute significantly toward efficiently completing a challenging case. Surgical proficiency requires a well-planned approach with an appreciation and knowledge of the instruments and sutures to be used.
SURGICAL INSTRUMENTATION
Every surgeon has a preference for selecting particular instruments as a result of training and experience. Later, these choices are often modified by acquired habits and limits imposed by cost. Surgical instruments are an extension of a surgeon’s hands and are designed to facilitate the operative procedure. The list of instruments provided in this chapter is neither comprehensive nor complete. What follows is a functional description of the basic tools for the gynecologic surgeon.
Scalpels
The Bard-Parker handle is usually fitted with a disposable blade that is attached using a needle holder. Commonly, the #10 or #20 blade is used for the skin incision and can then be used to extend the incision through the fascia. The #15 blade has a small area useful for confined spaces or small skin incisions. The #11 blade has a straight edge useful for its pointed design in placing drains or opening abscesses. There are also long and curved handles to facilitate dissection in the deep pelvis.
Scissors
Scissors, with their long handles and strong blades, serve multiple functions in the operative field from cutting sutures, excising scar tissue, and transecting pedicles to fine dissection of adhesions involving intra-abdominal viscera. Surgical scissors usually come in various sizes and lengths, with straight and curved blades having chamfered or rounded ends. Examples of these are the Mayo and Metzenbaum scissors. The Jorgenson scissors are heavy scissors with sharply curved blades that facilitate the amputation of the cervix off the vaginal cuff.
Forceps
Thumb forceps, as the term suggests, act as an extension of the surgeons thumb and index finger for grasping tissue, steadying needles, or exploration. Spring tension keeps the tips apart until pressure is applied to close them. Forceps have a variety of widths and lengths, making them versatile and universally applicable in the operative field. The blade’s design and surface configuration will determine its intended use. Adson forceps are used for manipulating the skin, whereas Bonney or Martin forceps have teeth for handling fascia. DeBakey or smooth forceps with a cross-serrated grasping surface make them ideal for handling peritoneum or vascular pedicles. Singley forceps with their fenestration are ideal in atraumatic handling of tissue bundles during lymphatic dissection. Hemostatic forceps (clamps) are light instruments with spring handles, ratcheting closing mechanisms, and fine tips, making them ideal for isolating bleeding points, grasping small vascular pedicles, and careful dissection in the pelvis. They come in an assortment of sizes and lengths, making them very useful instruments. The Halsted mosquito forceps, Kelly clamps, Tonsils, Rochester-Ochsner, and Mixter forceps are a few other often-used forceps.
Hysterectomy Clamps
Because of the rich, extensive, and collateralized blood supply to the uterus, these clamps are designed to secure and maintain large vascular pedicles within their jaws while minimizing the trauma to the surrounding tissue. A ratchet locking device in the handle, serrations in the jaw, and teeth at the tips allow for a pedicle to be transected and ligated safely. Tissue slippage can result in extensive bleeding that is difficult to control, risking injury to the ureters as well as larger vessels. These clamps are generally at least 20 cm long and have curved or straight jaws or angled handles. The longitudinal serrations tend to be preferred because they prevent slippage of tissue from the clamp. Examples include the Heaney-Ballentine clamps, which have teeth at their tips to ensure secure bite at the cost of crushing the tissue; the Masterson clamp, which was designed to generate less crushing force by lacking the toothed tip; and the Zeppelin clamps, which may best satisfy the requirements for the use in complex pelvic procedures—greater holding force and minimal tissue trauma and slippage. In addition to the full range of abdominal Zeppelin clamp configurations, different sizes and curves are also available for vaginal surgery (Figure 23-1).
FIGURE 23-1. Zeppelin clamps.
Clip Applicators
Clip applicators are effective in obtaining hemostasis of small vessels deep in the pelvis or when performing a lymph node dissection to prevent lymphatic drainage. The applicator comes as a reusable single clip applicator with straight or angled head or as a disposable instrument with multiple loads. The applicators usually come in 3 sizes: small, medium, and large. After clip application, caution should be used with the use of the electrosurgical unit or suction device because of potentially unrecognized injury by thermal spread or dislodged clips causing rents in serosal surfaces or vascular structures.
Retractors
Surgery for ovarian cancer is normally performed through a midline laparotomy because evaluation of both pelvic and abdominal structures is required. A self-retaining retractor is essential to optimizing exposure, maximizing patient safety, and reducing surgeon fatigue. Of the available models of self-retaining retractors, those with a fixed arm attaching the retractor ring to the operating table are best suited for ovarian cancer surgery. The Bookwalter retractor is the standard self-retaining fixed-ring retractor and is versatile enough to be adapted to a variety of operative requirements. The retractor clips that attach the blades to the ring allow for 2-dimensional adjustments of the blade position in relation to the surgical field. The oval ring of the Bookwalter is most commonly used for ovarian cancer surgery, but circular and hinged rings are also available depending on the exposure needed. For example, the hinged ring can be used to surgical advantage when operating in the upper abdomen (eg, diaphragm, liver, spleen) by increasing the angulation of the retractor blade to provide more pronounced ventral displacement of the costal margin, improving exposure.
The Omni retractor has 2 adjustable “boomerang-shaped” arms that are attached to a fixed post. Each arm can be moved in 3 dimensions, and finer modifications in exposure can be achieved with the adjustable retractor blades as opposed to the fixed ring. The Omni retractor is especially helpful when operating on obese patients, because the extent of lateral retraction is not limited by the width of a retractor ring (eg, Bookwalter). Nonfixed, self-retaining retractors, such as the Balfour and O’Connor-O’Sullivan retractors, can also be used, but they are more limited in their field of exposure and are less steady than the fixed models because they are stabilized only by creating pressure on the opposing sides of the abdominal wall incision. In addition to limited exposure, self-retaining retractors have been associated with iatrogenic nerve injury due to compression of the femoral nerve in as many as 7.5% of cases.1 Although retractors such as the Omni and Bookwalter may be associated with nerve injury as well, the elevation of the abdominal wall provided by these retractors may help to minimize this risk. With any self-retaining or fixed retractor, the surgeon must exercise particular attention when placing the blades along the lateral abdominal wall so as not to compress the psoas muscle and traumatize the underlying femoral nerve. The risk of femoral nerve injury may also be increased by extended Pfannenstiel incisions, thin habitus (body mass index < 20 kg/m2), narrow pelvis, and prolonged surgical time greater than 4 hours (Figure 23-2).
FIGURE 23-2. Bookwalter self-retaining retractor.
Needle Holders
The needle holder serves to guide and place a needle through tissue and then retrieve it. They are designed with various lengths and straight or curved jaws to facilitate their placement. A fine locking mechanism and serrated jaws assist with control of the needle to prevent unnecessary bleeding and tissue damage. Considerations for correct needle choice and caution with grasping the needle can prevent the needle from bending or breaking. Curved tips are preferred in vaginal surgery to aide with visualization and placement of the needle. However, the straight tip allows for better control of the needle with more precise placement. The Mayo-Hegar and DeBakey’s are 2 commonly used needle holders.
The Electrosurgical Unit and Vessel Sealant Devices
The electrosurgical unit (ESU) (Force 2; ValleyLab, Boulder, CO) consists of a generator and electrodes and is probably the most commonly used instrument in ovarian cancer surgery. The ESU uses radiofrequency electrosurgery to oscillate intracellular ions, which converts electromagnetic energy to mechanical energy and then to thermal energy. The ESU can be configured with either monopolar or bipolar electrodes. The monopolar electrode is versatile and can be used for cutting, desiccation, and fulguration. With cutting current, a continuous high-frequency flow leads to a rapid buildup of heat and vaporization of intracellular water, resulting in local tissue disintegration without a significant coagulative effect but with minimal lateral heat transfer. In contrast, coagulation mode uses an interrupted current of lower energy, which leads to a slower heating of intracellular water, increasing the resistance to flow and producing a more pronounced coagulative effect on small blood vessels. Often a combination (or blended) current produces the most satisfactory tissue effect. Generally the lowest effective generator settings should be used to avoid excessive thermal damage to surrounding tissues. Customary settings for blended currents range from 30 to 50 W. With monopolar electrodes, a grounding or dispersive pad needs to be applied to non–hair bearing, well-perfused, and dry skin close to the surgical site. The bipolar electrode uses a dual paddle design that conducts current to produce a tissue-coagulating effect. Bipolar devices conduct current only between the 2 paddles of the instrument, limiting the risk of electrical injury, especially when used during laparoscopy.
Automated Stapling Devices
Advanced-stage ovarian cancer commonly involves the intestinal tract by contiguous extension or distant peritoneal metastasis. Consequently, the surgeon must be familiar with a variety of techniques of bowel resection and anastomosis. Traditionally, these procedures were performed using hand-sewn suture techniques. The introduction of automated surgical stapling devices permits the same procedures to be performed with comparable efficacy, greater simplicity, and increased speed. There are multiple brands of commercially available automated stapling devices; however, all use the same basic principle of compressing an inverted “U-shaped” staple into a “sideways B” in the closed position. The closed staple position secures the tissue contained within but does not constrict the vascular supply to the resulting staple line with the exception of the vascular load staplers.
There are 3 basic categories of automated stapling devices used for bowel surgery as well as other purposes. All contemporary stapling devices are single-use and disposable. The first category is the thoracoabdominal (TA) stapler, which lays down a double row of titanium staples staggered in an overlapping fashion. The TA stapler does not have a cutting component and therefore is used to close a segment of intestinal tract distal to the point of division or to close an enterotomy or colostomy created during one of various anastomotic techniques. The TA stapler is available in 3 different sizes (40, 60, and 90 mm) depending on the width of tissue to be secured. There are 2 standard staple sizes for the TA stapler, with the choice being dependent on the compression thickness of the stapled tissue. The 3.5-mm staple (open position) compresses to a thickness of approximately 1.5 mm in the closed position, whereas the 4.8-mm staple (open position) should be used for tissue that will compress to approximately 2.0 mm in the closed position. The Roticulator stapling device is a variation of the standard TA stapler that incorporates a rotating shaft and hinged cartridge head to allow greater flexibility of application. It is particularly useful when dividing a segment of colon or rectum deep in the pelvis. The Roticulator lays down a double row of 4.8-mm titanium staples 55 mm in length.
The second category of automated stapling devices is the gastrointestinal anastomosis (GIA) stapler, which lays down 2 double rows of staggered titanium staples and has a self-contained cutting blade that divides the tissue between the 2 staple lines. The GIA stapler is used to simultaneously secure and divide a segment of bowel or other tissue such as mesentery and is available in 2 lengths (60 and 80 mm) depending on the width of tissue. The basic staple sizes adapted for use in the GIA stapler are 3.8 mm, which compresses to 1.3 mm in the closed position, and 4.8 mm, which compresses to 2.0 mm in the closed position. Vascular load staple cartridges are also now in use with the GIA-type staplers that have a staple size of 2.5 mm, which compresses to 1.0 mm in the closed position. The staple line thus created is hemostatic for most small-caliber vascular pedicles.
The third category of automated stapling devices is the circular end-to-end anastomosis (CEEA) stapler. The CEEA stapler lays down a double row of circular staples and has a self-contained circular cutting blade that simultaneously excises the inverted internal tissue. The 4.8-mm staples compress to a tissue thickness of approximately 2 mm. The CEEA stapler is most commonly used to create end-to-end anastomosis of the colon but is also applicable to small bowel–small bowel and small bowel–colon anastomosis. Both straight and curved shafts are available variations of the CEEA stapler, although when performing a low colorectal anastomosis, navigation of the pelvic curvature is usually easier with the curved model. A low-profile detachable anvil is also available for the CEEA stapler, which is easier to place within the bowel lumen in some circumstances (eg, stapled end-to-side anastomosis). The standard CEEA stapler comes in 5 sizes that reflect the outer diameter of the circular stapler cartridge: 21, 25, 28, 31, and 33 mm. In general, the functional luminal diameter is approximately 10 mm smaller than the size of the stapler used to create the anastomosis.
Successful outcomes using automated surgical stapler to perform bowel anastomosis including colorectal anastomosis below the levator muscles have been reported in the gynecologic literature since the late 1970s. The rate of enteric anastomotic-related complications following trauma-related intestinal surgery has been confirmed to be similar regardless of whether an automated stapler or hand-sewn technique is used. In one of the largest case series documenting the use of end-to-end anastomosis stapling devices in the setting of radical gynecologic surgery, the 2 anastomotic breakdowns reported were noted in patients who had previously undergone radiation therapy.2 Some authors argue that the favorable outcomes associated with the use of automated stapling devices in patients with gynecologic malignancies are due, at least in part, to the improved blood flow to the anastomosis, a contention that has been confirmed in an animal model. It must be stressed that, in all instances, the method of anastomosis elected should reflect the technique with which the surgeon is the most comfortable. The specifications of the 3 types of automated stapling devices are depicted in Figures 23-3, 23-4, and 23-5.
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